Ketamine for the Treatment of Depression and Other Psychiatric Disorders
Defines Kaiser Permanente's medical necessity and coverage stance for ketamine (intranasal, intravenous, subcutaneous) when used to treat depression, PTSD, suicidal ideation, chronic pain, substance use disorder, and other psychiatric diagnoses for members of Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.
Added CPT code 90792 and language clarifying that evaluations for the explicit purpose of Ketamine treatment will also be reviewed against clinical criteria for Ketamine therapy.
Updated notice timing and removed 'oral' route per Pharmacy in 06/21/2022 revision.
Adopted a policy of non-coverage for IV ketamine for mental diagnoses including chronic pain, depression, anxiety disorders, substance use disorder and suicidal ideation.
Coverage Criteria
Coverage stance
Covered status
See policy for Medicare application and non‑Medicare non‑coverage details; evaluations for the explicit purpose of ketamine treatment will be reviewed against clinical criteria for ketamine treatment.
Ketamine administered via intranasal, intravenous, or subcutaneous routes is considered experimental and investigational for Non‑Medicare members because its clinical value for psychiatric and related indications has not been established. As a result, these uses are not covered for Non‑Medicare members. Evaluations performed explicitly for the purpose of providing ketamine treatment will be reviewed against clinical criteria for ketamine therapy. Esketamine (Spravato) is reviewed separately under pharmacy criteria.
Use of ketamine for the following psychiatric and suicidal‑related diagnoses and related codes is considered not medically necessary (experimental, investigational, or unproven) and is not covered for Non‑Medicare members: mood disorders (e.g., F30–F39), anxiety and stress‑related disorders (e.g., F40–F48), schizophrenia and other psychotic disorders (F20–F29), substance‑related disorders (F10–F19), behavioral syndromes and personality disorders (F50–F69), intellectual and developmental disorders (F70–F89), unspecified mental disorders (F99), and a range of suicidal behavior and ideation codes (including T14.91XA, R45.89, R45.851, T50.902A). Chronic pain diagnoses (e.g., G89 series, G90.51x–G90.52x) are also listed as not medically necessary when ketamine is requested for treatment.
Coding
| F01-F09 | Mental disorders due to known physiological conditions |
| F10-F19 | Mental and behavioral disorders due to psychoactive substance use |
| F20-F29 | Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders |
| F30-F39 | Mood [affective] disorders |
| F40-F48 | Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders |
| F50-F59 | Behavioral syndromes associated with physiological disturbances and physical factors |
| F60-F69 | Disorders of adult personality and behavior |
| F70-F79 | Intellectual disabilities |
| F80-F89 | Pervasive and specific developmental disorders |
| F90-F98 | Behavioral and emotional disorders with onset usually occurring in childhood and adolescence |
Provider Actions & Requirements
Authorization and relevant codes (verify via Pre-authorization Code Check)
Certain CPT/HCPCS and psychiatric evaluation codes are identified in the policy and may trigger plan-specific authorization requirements; verify via the Pre-authorization Code Check before submitting. Codes called out include J3490 (Unclassified drugs), commonly submitted infusion administration CPT codes 96365–96368, and psychiatric diagnostic evaluation code 90792.
Step therapy — none specified; non‑Spravato ketamine non‑covered
There are no step therapy pathways described in this policy. For non‑Spravato ketamine (intranasal, intravenous, or subcutaneous), the policy considers it experimental/investigational and non‑covered for non‑Medicare members.
- No step therapy requirements are specified in the policy
- Non‑Spravato ketamine is considered experimental/investigational and not covered for non‑Medicare members
Required documentation for review — last 6 months of clinical notes
When requesting review for this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support the request.
- Include clinical notes covering the most recent 6 months from the requesting provider and/or specialist
Non‑covered indications for ketamine (risk of denial)
Requests for ketamine (intranasal, intravenous, or subcutaneous) for non‑Medicare members are considered experimental and investigational and are not covered for diagnoses including but not limited to chronic pain, depression, generalized/social anxiety disorders, substance use disorder, and suicidal ideation; such requests may be denied.
- Non‑covered diagnostic examples: chronic pain; depression; generalized anxiety and social anxiety disorders; substance use disorder; suicidal ideation
- Policy lists related CPT/HCPCS and ICD‑10 codes as considered not medically necessary for these uses
- Evaluations conducted explicitly for Ketamine treatment will be reviewed against clinical criteria for Ketamine treatment
Background
Evidence supporting ketamine for psychiatric indications is limited and generally low quality. Single‑dose ketamine infusions have been shown in small, low‑quality studies to produce rapid symptom reduction in severe unipolar and bipolar depression, posttraumatic stress disorder, and suicidal ideation over short follow‑up periods (approximately 24 hours to a few days), but durability beyond one to four weeks is inconsistent. The long‑term safety and effectiveness of repeated dosing remain uncertain, and intravenous infusion is the most commonly studied route given ketamine’s low oral bioavailability and concerns about potential for abuse.
Definitions & Evidence Summary
Treatment Modalities
Ketamine infusion/administration (IV, intranasal, subcutaneous)
Covered modalities and summary of evidence/stance
IV infusion is the common route due to poor oral bioavailability; see evidence summaries for short-term benefit and uncertain longer-term safety of repeated dosing.
Revision History
Added CPT code 90792 and clarified that psychiatric evaluations performed for the explicit purpose of ketamine treatment will be reviewed against the clinical criteria for ketamine therapy.
Updated the 60-day notice date to 12/1/2022 and removed references to the 'oral' route per Pharmacy.
MPC adopted a policy of non-coverage for intravenous ketamine for mental health diagnoses including chronic pain, depression, anxiety disorders, substance use disorder, and suicidal ideation.
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