CurrentKaiser PermanentePolicy N/A

Ketamine for psychiatric disorders — Clinical Review Criteria

Defines Kaiser Permanente Washington's clinical review criteria and coverage stance for ketamine (IV, intranasal, subcutaneous) when requested for psychiatric diagnoses; applies to providers serving Kaiser members in WA (plan-specific).

Policy Summary

PayerKaiser Permanente

PolicyKetamine for psychiatric disorders — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeOperational — codes and review guidance added

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the last 6 months of clinical notes from the requesting provider and/or specialist when requesting review for ketamine treatment.

SourceLink

POLICY UPDATE CHANGES

Added CPT code 90792 and language clarifying that evaluations conducted for the explicit purpose of ketamine treatment will be reviewed against clinical criteria for ketamine therapy.

Non-coveredPayer stance

Experimental/InvestigationalDiagnostic groups

90792New code

Short-term benefitEvidence

Coverage Determinations and Rationale

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Non-coverage for psychiatric indications

Covered when ALL of the following are met:

Non-Medicare member coverage stance: Ketamine administered intranasally, intravenously, or subcutaneously for chronic pain or psychiatric diagnoses (including depression, substance use disorder, generalized and social anxiety disorders, and suicidal ideation) is considered experimental and investigational and is non-covered for non-Medicare members.

Evaluations for the explicit purpose of ketamine treatment will also be reviewed against clinical criteria for ketamine treatment.

Evidence limitations

Summary of key evidence limitations that inform the coverage decision:

Clinical evidence limitations: Randomized and other studies show single-dose ketamine reduces symptoms of treatment-resistant unipolar depression, PTSD, or suicidal ideation at short-term follow-up (1–3 days); however, durability to 2–4 weeks is mixed. Most studies administered only a single dose, and the safety and effectiveness of repeated administration are unknown.

Additional large, well-designed studies with adequate follow-up are needed to evaluate long-term effects, repeated dosing safety, and alternative routes (intranasal, subcutaneous) and to compare to ECT.

Non-covered diagnoses include, but are not limited to: depression; substance use disorder; generalized anxiety disorder and social anxiety disorder; and suicidal ideation.

For non‑Medicare members, ketamine administered intranasally, intravenously, or subcutaneously for the psychiatric diagnoses listed above is considered investigational/unproven and is not covered because its clinical value for these indications has not been established.

Applicable Billing and Diagnosis Codes

Applicable/Cited CPT/HCPCS codesmixed

90792	Psychiatric diagnostic evaluation with medical services.
J3490	Unclassified drugs.
96365	Commonly submitted with infusion codes (see document).
96366	Commonly submitted with infusion codes (see document).
96367	Commonly submitted with infusion codes (see document).
96368	Commonly submitted with infusion codes (see document).

Examples of diagnosis codes cited as experimental/investigationalICD-10Experimental

F30-F39	Mood [affective] disorders.
F40-F48	Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders.
F10-F19	Mental and behavioral disorders due to psychoactive substance use.
G89.21	Chronic pain due to trauma.
G90.511	Complex regional pain syndrome of right upper limb.

Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Requests for ketamine (intranasal, intravenous, or subcutaneous) for psychiatric indications or chronic pain require prior authorization review. Use the Pre-authorization Code Check to verify requirements by plan type.

Prior authorization required for IV/IN/SC ketamine for non‑Medicare members as experimental/investigational for listed psychiatric and many pain indications
Verify authorization requirements by plan using the Pre-authorization Code Check

Step Therapy

Step Therapy Guidance

Step therapy: There is no specified step‑therapy pathway in this policy. Ketamine (including IV/IN/SC) is generally regarded as an uncommon later‑line option given limited durability of effect, potential for abuse, and limited evidence for repeated administration; expect ketamine to be positioned after standard pharmacologic and guideline‑directed therapies.

Documentation Required

Required Documentation for Review

Documentation Required: Submit the last 6 months of clinical notes from the requesting provider and/or specialist. Include diagnostic evaluation details, targeted diagnosis, prior treatments tried and responses, treatment plan (dose, route, frequency), informed consent discussion of risks/benefits, and monitoring plan for adverse effects.

Required: Last 6 months of clinical notes from requesting provider and/or specialist
Include prior treatment history, objective assessment, planned ketamine regimen (route, dose, frequency), and monitoring/safety plan

Denial Risk

Denial Risk — Non‑covered Psychiatric Indications

Denial Risk — Non‑covered Psychiatric Indications: Ketamine for psychiatric diagnoses listed as experimental/investigational will be denied. Non‑covered examples include depression, substance use disorders, generalized anxiety disorder, social anxiety disorder, and suicidal ideation. Evaluations performed solely for the purpose of ketamine treatment will be reviewed against these criteria and may be denied.

Non‑covered psychiatric indications (examples): Depression; Substance use disorder; Generalized anxiety disorder; Social anxiety disorder; Suicidal ideation
Esketamine (Spravato) follows separate pharmacy criteria and is reviewed separately

Billing Rule

Authorization and Commonly Submitted Codes

Commonly Submitted Codes: Include the psychiatric diagnostic evaluation code and any administration/infusion codes on prior authorization and claims submissions to support medical necessity.

90792 — Psychiatric diagnostic evaluation with medical services (suggested when evaluation performed)
J3490 — Unclassified drugs (commonly used for ketamine when no specific HCPCS exists)
96365, 96366, 96367, 96368 — Therapeutic/prophylactic/diagnostic injection/infusion administration codes (commonly submitted with ketamine administration)
ICD‑10 codes commonly associated with submitted requests may include F01‑F09, F10‑F19, F20‑F29 and pain codes such as G89.x and G90.x; verify diagnosis coding accuracy

Key Definitions and Concepts

Treatment‑resistant unipolar depression / PTSD — definition and evidence summary

DefinitionSevere depressive or posttraumatic stress disorder symptoms that have not responded to standard therapies; typically described as treatment-resistant unipolar depression or PTSD.

Evidence of benefitSingle-dose ketamine reduces symptoms at short-term follow-up (1–3 days) for treatment-resistant unipolar depression, PTSD, and suicidal ideation.

DurabilityFindings at longer-term follow-up (up to ~4 weeks) are mixed; short-term benefits often wane after days to weeks.

Repeated dosingMost studies used only a single dose; the safety and effectiveness of repeated administration are unknown.

Safety noteAvailable evidence suggests ketamine is reasonably safe when complications are properly managed, but additional large studies with adequate follow-up are needed.

Route considerationsKetamine is commonly given by infusion because of poor bioavailability via some alternative routes; further evaluation of intranasal and subcutaneous administration is needed.

Modality-Specific Notes (IV / Intranasal / Subcutaneous)

Ketamine (IV, intranasal, subcutaneous)

Modality-level observation (any of the following applies):

Ketamine treatment evidence: Single-dose ketamine shows short-term symptom improvement; repeated administration safety and effectiveness are unknown. Ketamine is typically administered by infusion due to poor bioavailability by alternative routes; evidence for simplified intranasal or subcutaneous administration is limited.

Includes observations for unipolar and bipolar depression, PTSD, and suicidal ideation; durability beyond a few days is inconsistent.

Policy Changes and Review Notes

2024-06-03Operational updateLatest

Added CPT code 90792 and clarified that evaluations conducted for the explicit purpose of ketamine treatment will be reviewed against clinical criteria for ketamine therapy.

2023-12-09Review

Medical Policy Committee review recorded (MPC review date).

2022-12-06Review

Medical Policy Committee review recorded (MPC review date).

2021-12-07Policy adoption

MPC approved adoption of a policy of non-coverage for IV ketamine for mental health diagnoses including chronic pain, depression, generalized and social anxiety disorders, and substance use disorders.

OpenPayer