Ketamine Infusions
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This policy governs prior authorization and clinical criteria for ketamine infusion therapy as a medical benefit for members of Hennepin Health, including initial approval and renewal requirements.
No material clinical or coverage changes in this revision.
Coverage criteria for ketamine infusions
inv-01: Initial approval
Covered when ALL of the following are met
inv-02: Renewal
Renewal covered when ALL of the following are met
This policy governs prior authorization and medical- benefit coverage for ketamine infusions. Prior authorization is required; initial requests will be evaluated against the clinical criteria below and may be denied if criteria are not met. For initial approval, all of the following must be documented: the member meets all esketamine (Spravato) criteria as determined using InterQual criteria utilized by Hennepin Health; the member has had an inadequate response to esketamine (Spravato); and the ketamine infusions are requested as a medical benefit. Initial approval is for 3 months when criteria are satisfied.
Initial therapy
inv-11: Initial approval
Continuation / Renewal criteria
inv-12: Renewal
Provider actions and authorization
Prior authorization required
Prior authorization is required for ketamine infusions; initial requests will be evaluated against the policy's clinical criteria and, if approved, are authorized for 3 months.
Esketamine (Spravato) prerequisite
Member must have had an inadequate response to esketamine (Spravato) and must meet all esketamine (Spravato) criteria (as determined using InterQual criteria utilized by Hennepin Health) prior to approval of ketamine infusions.
- The member meets all esketamine (Spravato) criteria, as determined using InterQual criteria utilized by Hennepin Health.
- The member has had an inadequate response to esketamine (Spravato).
Renewal documentation required
For renewal, documentation must include a clinician evaluation within the previous 3 months and documentation showing clinical improvement in depressive symptoms; renewals may be approved for up to 6 months.
- Clinician evaluation within the previous 3 months.
- Documentation of clinical improvement in depressive symptoms.
Denial triggers — missing authorization or unmet criteria
Requests submitted without prior authorization or that do not meet the listed clinical criteria — including failure to meet esketamine (Spravato) criteria or lack of inadequate response to esketamine — may be denied.
Step therapy requirements
| Step | Requirement |
|---|---|
| 1 | Member must meet all esketamine (Spravato) criteria as determined using InterQual criteria utilized by Hennepin Health, and have an inadequate response to esketamine (Spravato) prior to approval; ketamine infusions must be requested as a medical benefit. Initial approval duration: 3 months. |
Site of care requirements
Request as medical benefit (infusion center)
Ketamine infusions must be requested as a medical benefit (i.e., administered in a facility/medical setting rather than as a pharmacy-dispensed outpatient agent).
Definitions and scope
Background
Ketamine is recognized in this policy as both a general anesthetic and an agent with antidepressant effects. This policy specifically addresses the use of ketamine as an infusion therapy for depressive disorders in which esketamine (Spravato) criteria have been applied and an inadequate response to esketamine has been documented. Ketamine infusions must be requested as a medical benefit (i.e., administered in a medical/infusion setting) and will be reviewed under the approval criteria outlined in this policy.
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