ModifiedUnitedHealthcarePolicy 2026D0069P

Ketalar (Ketamine) and Spravato (Esketamine) Medical Benefit Drug Policy

Policy Summary

PayerUnitedHealthcare

PolicyKetalar (Ketamine) and Spravato (Esketamine) Medical Benefit Drug Policy

Policy CodePolicy 2026D0069P

Change TypeHCPCS code updates (added J0013; removed S0013)

Effective DateJan 1, 2026

Next Review Date

Key ActionReport ketamine injection using J0013 (injection, ketamine HCl, 10 mg) as the applicable HCPCS J-code effective with the policy update; do not use removed code S0013.

POLICY UPDATE CHANGES

Added J0013 to the list of applicable HCPCS codes.

Removed S0013 from the list of applicable codes.

Archived previous policy version 2025D0069O.

1Added HCPCS codes

1Removed codes

Coverage Summary

Part 2 of 2 contains references, policy history/revision information documenting coding updates (HCPCS/HCPCS-like codes), instructions for use, and general applicability notes for the UnitedHealthcare medical-benefit drug policy for ketamine and esketamine. It governs interpretation and application of the medical benefit policy and notes code additions/removals effective 2026-01-01. This document is the second part of a two-part policy package and focuses on coding updates and supporting references for ketamine and esketamine medical-benefit policy. The overall coverage stance for the policy materials in this part is mixed.

Policy summary

Policy number2026D0069P

PayerUnitedHealthcare

Policy titleKetalar (Ketamine) and Spravato (Esketamine) Medical Benefit Drug Policy - applicable HCPCS/HCPCS coding updates and references

Effective dateJanuary 1, 2026

Last review2026-01-01

Change statusMODIFIED

Key actionUpdated applicable HCPCS/J-codes: added J0013 and removed S0013 (annual edits); supporting information updated and prior version archived.

Added codes (count)1

Removed codes (count)1

Applicable Codes

Applicable HCPCS/J-codes updatedHCPCSCovered

J0013

Injection, ketamine HCl, 10 mg (added)

Removed codesmixedNot Covered

S0013

Previously listed code removed from applicable codes

Coding updates in this policy are material. The annual edits to the list of applicable HCPCS codes include the addition of J0013 and the removal of S0013. These coding changes are effective 2026-01-01 and are documented in the policy history.

Provider Actions & Billing Rules

Billing Rule

Use updated HCPCS J-code for ketamine injection

Report ketamine injection using HCPCS J0013 (injection, ketamine HCl, 10 mg) as the applicable J‑code effective with this policy update. Do not use the removed code S0013 for ketamine injection. This coding change is effective as of the policy update.

J0013
S0013

Documentation Required

Reference member-specific benefit plan

Check the member-specific benefit plan document and any applicable federal or state mandates before applying this policy. The member-specific plan governs in the event of a conflict.

Operational note: This Medical Benefit Drug Policy provides assistance in interpreting UnitedHealthcare standard benefit plans; the member-specific benefit plan document governs in the event of conflict. Before applying the policy, check the member-specific benefit plan and any applicable federal or state mandates. In certain instances, and in the absence of a Medicare NCD or LCD or other Medicare coverage guidance, this policy may be applied to Medicare Advantage plans using objective evidence-based rationale.

Clinical Evidence & Safety Notices

Background and evidence summary: The policy cites multiple randomized controlled trials and phase 3 studies supporting rapid reduction of depressive symptoms and suicidality with esketamine, including the ASPIRE I & II trials and other phase 3 studies (references such as ASPIRE I & II, TRANSFORM, SUSTAIN, and Popova et al).

Systematic reviews and meta-analyses are referenced that evaluate intranasal esketamine and intravenous ketamine RCT data, showing rapid antidepressant effects in the short term (examples include pooled RCT meta-analyses and systematic reviews noted in the references).

Safety communication: The FDA issued a safety communication warning about potential risks associated with compounded ketamine products (News release dated October 10, 2023).

Background & Scope

This part of the policy is intended to provide the supporting references and policy history related to HCPCS/HCPCS-like coding updates and to assist in interpretation of UnitedHealthcare standard benefit plans for ketamine and esketamine. It may be applied to Medicare Advantage plans when no NCD/LCD or other Medicare guidance exists. The FDA safety communication regarding risks of compounded ketamine products is documented as a News release on October 10, 2023.

Revision History

2026-01-01code updateLatest

Added J0013 to the list of applicable HCPCS codes (injection/administration coding updated).

2026-01-01code updateLatest

Removed S0013 from the list of applicable codes.

2026-01-01otherLatest

Archived previous policy version 2025D0069O; supporting information updated.

Policy Summary

PayerUnitedHealthcare

PolicyKetalar (Ketamine) and Spravato (Esketamine) Medical Benefit Drug Policy

Policy CodePolicy 2026D0069P

Change TypeHCPCS code updates (added J0013; removed S0013)

Effective DateJan 1, 2026

Next Review Date

Key ActionReport ketamine injection using J0013 (injection, ketamine HCl, 10 mg) as the applicable HCPCS J-code effective with the policy update; do not use removed code S0013.

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