Psychiatry - Spravato
Defines Cigna prior authorization, coverage criteria, dosing approvals, and coding for Spravato (esketamine nasal spray) for FDA‑approved indications in adults under Cigna-administered health benefit plans.
Updated initial approval duration to 2 months for MDD with Acute Suicidal Ideation or Behavior and 6 months for Treatment-Resistant Depression.
Changed prescribing requirement from 'by a psychiatrist' to 'by or in consultation with a psychiatrist or a mental health provider'.
Added documentation requirement language specifying documentation may include chart notes, labs, claims records, or other information.
Added HCPCS code J0013 (Esketamine, nasal spray, 1 mg) effective 1/1/2026 and updated S0013 description noting its effective through 12/31/2025.
Coverage Criteria for Spravato (esketamine)
FDA-Indication: MDD with Acute Suicidal Ideation or Behavior
Covered when ALL of the following are met for MDD with Acute Suicidal Ideation or Behavior:
Approve for 2 months; dosing: maximum single intranasal dose 84 mg; twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability).
FDA-Indication: Treatment-Resistant Depression
Covered when ALL of the following are met for Treatment-Resistant Depression (TRD):
Approve for 6 months; dosing: induction Weeks 1-4 twice weekly (56 or 84 mg), Weeks 5-8 once weekly, Week 9+ individualized to maintain response (every 2 weeks or once weekly) at 56 or 84 mg; may be used as monotherapy or in conjunction with an oral antidepressant.
Administration and Monitoring Requirements
Post-administration monitoring:
Administration must occur under direct supervision of a healthcare provider; REMS enrollment required for setting and patient.
Spravato (esketamine) for any use other than the FDA‑approved indications listed in this policy is considered not medically necessary. Receipt of sample product does not satisfy any criteria requirements for coverage.
Use of Spravato for indications outside the FDA‑approved uses listed in this policy is considered not medically necessary.
Billing and Coding
| J0013 | Esketamine, nasal spray, 1 mg (Code effective 1/1/2026). |
| S0013 | Esketamine, nasal spray, 1 mg (Code effective until 12/31/2025) |
| G2082 | Office or other outpatient visit for established patient requiring supervision and provision of up to 56 mg esketamine nasal self-administration, includes 2 hours post administration observation. |
| G2083 | Office or other outpatient visit for established patient requiring supervision and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post administration observation. |
Provider Actions, Prior Authorization & Documentation
Prior authorization required
Prior authorization is required for benefit coverage of Spravato. Approvals are provided for the durations specified in the policy: 2 months for Major Depressive Disorder with Acute Suicidal Ideation or Behavior and 6 months for Treatment‑Resistant Depression when the patient meets the Criteria and Dosing. Requests for doses outside the established dosing in this policy will be considered case‑by‑case by a clinician.
- All approvals are provided for the duration noted; 1 month = 30 days.
- Approval requires Spravato be prescribed by or in consultation with a psychiatrist or a mental health provider.
Prior treatment requirement for TRD
For Treatment‑Resistant Depression (TRD), the policy requires documentation that the patient demonstrated nonresponse (≤25% improvement in depression symptoms or scores) to at least two different antidepressants, each from a different pharmacologic class, and that each antidepressant was used at therapeutic dosages for at least 6 weeks in the current episode.
- Different pharmacologic classes include SSRIs, SNRIs, TCAs, bupropion, mirtazapine, etc.
- Documentation of prior antidepressant trials is required as noted in the criteria.
Provide documentation to support criteria
Documentation is required where noted in the criteria and may include chart notes, laboratory tests, claims records, and/or other information to support required elements such as prior antidepressant trials, severity, and concomitant antidepressant use.
- Examples of acceptable documentation: chart notes, laboratory tests, and claims records.
- Documentation is specifically required for prior treatment trials and concomitant oral antidepressant use as indicated in the criteria.
Denials for missing codes, unmet criteria, or off‑policy dosing
Claims submitted without covered diagnosis or procedure codes or that do not meet the policy criteria will be denied as not covered; requests for doses outside the established dosing documented in this policy will be reviewed case‑by‑case and may be denied.
- When billing, providers must use the most appropriate codes as of the effective date of the submission; claims without covered codes will be denied.
- Dose requests outside policy dosing are subject to clinician review (e.g., Medical Director or Pharmacist).
Background
Spravato (esketamine) is an N‑methyl‑D‑aspartate (NMDA) receptor antagonist indicated for adults with major depressive disorder (MDD) with acute suicidal ideation or behavior (to be used in conjunction with an oral antidepressant) and for treatment‑resistant depression (TRD) (as monotherapy or with an oral antidepressant). The product labeling includes a boxed warning for sedation, dissociation, respiratory depression, abuse/misuse, and suicidal thoughts/behaviors in youth, and Spravato is available only through a REMS program requiring administration in a REMS‑certified healthcare setting with patient monitoring of at least 2 hours post‑dose.
Definitions
Level of Care / Setting Requirements
Treatment Modalities
Pharmacologic (Spravato/esketamine)
Spravato must be administered under direct supervision in a REMS-certified setting; not an anesthetic.
Visit Limits and Approval Durations
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