CurrentOptumPolicy N/A

IV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)

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Governance of coverage, prior authorization, provider attestation, allowable settings, and billing submission processes for IV ketamine infusion therapy for members with major depressive disorder under Optum/UnitedHealthcare Community Plan (applies to ForwardHealth/BadgerCare Plus/Wisconsin Medicaid SSI).

Policy Summary

PayerOptum (ForwardHealth/UnitedHealthcare Community Plan)

PolicyIV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)

Policy CodePolicy N/A

Change TypeNew coverage effective 2025-01-01

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization via the UnitedHealthcare Provider Portal with supporting clinical records and the completed IV Ketamine Infusion Therapy Attestation Form (F-03342).

SourceLink

POLICY UPDATE CHANGES

ForwardHealth began covering IV Ketamine infusion therapy on Jan. 1, 2025 for eligible members who meet clinical and administrative requirements.

1Attestation form required

ACLSACLS on site

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CurrentOptumPolicy N/A

IV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)

Customize your policy alerts

Sign up for all Optum policy alerts

Know when Optum releases new policies or updates existing guidance.

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Policy Summary

PayerOptum (ForwardHealth/UnitedHealthcare Community Plan)

PolicyIV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)

Policy CodePolicy N/A

Change TypeNew coverage effective 2025-01-01

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization via the UnitedHealthcare Provider Portal with supporting clinical records and the completed IV Ketamine Infusion Therapy Attestation Form (F-03342).

SourceLink

POLICY UPDATE CHANGES

ForwardHealth began covering IV Ketamine infusion therapy on Jan. 1, 2025 for eligible members who meet clinical and administrative requirements.

1Attestation form required

ACLSACLS on site

DEA-registeredPrescriber registration

Portal-onlySubmission channel

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met:

Eligibility and indication: Member diagnosed with major depressive disorder (MDD), with or without suicidality.

Prior authorization and documentation: A prior authorization request is submitted via the UnitedHealthcare Provider Portal and includes supporting clinical information, a copy of the member's current medical records, and the completed IV Ketamine Infusion Therapy Attestation Form (F-03342).

Provider qualifications and protocols: Prescriber is registered with the DEA and has attested that treatment and monitoring protocols are in place and that ACLS-certified staff are on site during infusion.

Indication restriction: Treatment is for MDD only; ForwardHealth will not approve prior authorization requests for other off-label indications for IV ketamine.

ForwardHealth will not approve prior authorization requests for any other off‑label indication for IV ketamine.

Requests for IV ketamine for indications other than major depressive disorder (MDD) are not approvable; ForwardHealth explicitly does not approve off‑label indications for IV ketamine.

Coding and Diagnosis

Billing and portal guidancemixed

No codes listed

Covered diagnosis — Major depressive disorder (MDD)

Covered diagnosisMajor depressive disorder (MDD) — with and without suicidality

Eligible populationsBadgerCare Plus and Wisconsin Medicaid SSI members

Required prescriber registrationPrescriber must be registered with the DEA

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization — submit via UHC Provider Portal

Prior authorization is required for IV ketamine infusion therapy and must be submitted through the UnitedHealthcare Provider Portal (UHCprovider.com). Submissions via other portals will not be accepted.

Step Therapy

Step therapy — none specified

No step therapy requirements are specified in this policy document.

Documentation Required

Required documentation to support prior authorization

Level of Care Criteria

Treatment Modalities

IV ketamine infusion

Modality specifics: IV ketamine infusion therapy provided in allowable infusion settings by a DEA-registered prescriber who has completed and submitted the IV Ketamine Infusion Therapy Attestation Form (F-03342) certifying that treatment and monitoring protocols are in place and that ACLS-certified staff are on site during infusions.

Background

This policy governs coverage of IV ketamine infusion therapy for members diagnosed with major depressive disorder (MDD). Coverage is available when prior authorization is obtained through the UnitedHealthcare Provider Portal and the authorization request includes supporting clinical information, a copy of the member’s current medical records, and the completed IV Ketamine Infusion Therapy Attestation Form (F-03342). Requests submitted without the completed attestation form will be returned to the provider, and submissions sent via the Optum Behavioral Health Provider Express portal will be denied and must be resubmitted via the UnitedHealthcare Provider Portal. ForwardHealth will not approve prior authorization requests for any other off‑label indication for IV ketamine.

Definitions

Major Depressive Disorder (MDD) — definition / covered indication

Definition (covered indication)Major depressive disorder (MDD) with and without suicidality

Coverage settingIV ketamine infusion therapy when prior authorization and required protocols are in place

Provider qualificationsTreatment may only be rendered by a prescriber who is registered with the DEA

IV Ketamine Infusion Therapy Attestation Form (F-03342) — form and requirements

Form name and identifierIV Ketamine Infusion Therapy Attestation Form (F-03342)

PurposePrescriber must complete and include the form with the prior authorization request to attest to required protocols and on-site coverage

Policy Summary

PayerOptum (ForwardHealth/UnitedHealthcare Community Plan)

PolicyIV Ketamine Infusion Therapy — Coverage Criteria (ForwardHealth)

Policy CodePolicy N/A

Change TypeNew coverage effective 2025-01-01

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization via the UnitedHealthcare Provider Portal with supporting clinical records and the completed IV Ketamine Infusion Therapy Attestation Form (F-03342).

SourceLink

On This Page

Include supporting clinical information and a copy of the member's current medical records with the authorization request; also attach the completed IV Ketamine Infusion Therapy Attestation Form (F-03342).

Supporting clinical information
Copy of the member's current medical records
Completed IV Ketamine Infusion Therapy Attestation Form (F-03342)

Documentation Required

Attestation form (F-03342) must be completed and signed

The prescriber must include the completed IV Ketamine Infusion Therapy Attestation Form (F-03342) with the prior authorization request and sign it to attest that required protocols and ACLS coverage are in place.

Attests that a treatment protocol is in place
Attests that a monitoring protocol is in place
Confirms ACLS-certified staff are on site during infusion
Confirms prescriber is DEA-registered

Billing Rule

Submission channel — UHC portal only (Optum BH portal denied)

Do not submit prior authorization requests via the Optum Behavioral Health Provider Express secure portal; those submissions will be denied and must be resubmitted through the UnitedHealthcare Provider Portal.

Requests submitted via Optum Behavioral Health Provider Express will be denied
Denied requests must be resubmitted to UnitedHealthcare Provider Portal

Denial Risk

Missing attestation form — returned (delay/deny risk)

Requests submitted without the completed IV Ketamine Infusion Therapy Attestation Form (F-03342) will be returned to the provider, which may delay or prevent approval.

Incomplete requests will be returned to the provider

Note

Indication restriction — MDD only (no off‑label approvals)

ForwardHealth will not approve prior authorization requests for any off‑label indications for IV ketamine; treatment approval is limited to major depressive disorder (MDD).

Requests for indications other than MDD are not approvable

Attestation elementsMust attest that a treatment protocol and monitoring protocol are in place, ACLS-certified staff are on site during infusion, and the prescriber is DEA-registered