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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthUniversity of Utah KAP Coverage Policy | OpenPayer
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    CurrentUniversity of Utah Health PlansPolicy MP-054

    Ketamine-Assisted Psychotherapy (KAP)

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    This policy governs coverage of ketamine-assisted psychotherapy (KAP), including a one-time eligibility consultation and post-ketamine psychotherapy sessions, for University of Utah Health Plans Commercial, CHIP, and Medicaid members. Medicaid coverage follows Utah Medicaid policy when available; otherwise, the Commercial criteria apply when InterQual criteria are unavailable.

    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyKetamine-Assisted Psychotherapy (KAP)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMar 27, 2026
    Next Review DateFeb 27, 2027
    Key ActionDocument therapeutic goals, session content, KAP-related progression, gains, challenges or adverse events, and therapy timing for each integrated session.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1Covered eligibility consultation
    3Post-ketamine psychotherapy sessions covered
    1/dayMaximum sessions per day
    4Qualifying diagnosis categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1–3 days
    Initial integration therapy interval

    Coverage Criteria

    Initial eligibility consultation

    Covered for Commercial Plans and CHIP.

    One-time eligibility consultation: A one-time consultation with a psychiatrist, APRN, or PA to assess eligibility for Ketamine-Assisted Psychotherapy (KAP) is covered.One consultation

    Applies to Commercial Plans and CHIP.

    Post-ketamine assisted psychotherapy sessions

    Covered when ALL of the following are met.

    Post-ketamine psychotherapy coverage

    • Approved facility: Treatment is provided at an approved University of Utah Behavioral Health credentialed clinic.

    • ONE of the following qualifying diagnoses

      • Major depressive disorder: Major Depression Disorder.
      • Post-traumatic stress: Post-Traumatic Stress.
      • Anxiety disorder: Generalized and other anxiety disorders.
      • Obsessive-compulsive disorder: Obsessive-Compulsive Disorder.
    • Integration timing: Initial integration therapy sessions are scheduled within 1–3 days following a KAP session; same-day integration may be covered if clinically justified by the provider.1–3 days after KAP; same day only with clinical justification
    • Therapy focus: Post-ketamine assisted therapy sessions focus on processing and applying insights from KAP.Focus on processing and applying KAP insights
    • Session documentation: Each integrated session documents patient outcomes, including therapeutic goals, session content, and progression directly related to processing the KAP experience; observable patient outcomes across integrated sessions, including therapeutic gains, challenges, or adverse events; and the timing of integrated therapy related to KAP.All specified documentation elements
    • Onsite safety monitoring: The clinic has an RN, APRN, PA, or MD onsite to monitor member safety.At least one qualified clinician onsite
    • Qualified integration therapist: Integration therapy is provided by a licensed mental health provider, such as an LCSW, LPC, or LMFT, with relevant training or experience in KAP or psychedelic-assisted therapies.Licensed mental health provider with relevant KAP or psychedelic-assisted therapy training or experience

      Credentialed clinics must maintain and have available documentation of each provider’s qualifications and KAP-specific training.

    Medicaid coverage

    Medicaid coverage follows the applicable Utah Medicaid determination.

    Medicaid coverage pathway: Coverage is determined by the State of Utah Medicaid program. If Utah State Medicaid has no published coverage position and InterQual criteria are not available, the University of Utah Health Plans Commercial criteria apply.Utah Medicaid policy or, when unavailable, Commercial criteria if InterQual criteria are unavailable

    CPT and HCPCS codes covered by Utah State Medicaid may still require further evaluation to determine medical necessity for coverage.

    Coding and Billing Parameters

    Covered CPT CodesCPTCovered
    90832Psychotherapy, 30 minutes with patient
    90834Psychotherapy, 45 minutes with patient
    90837Psychotherapy, 60 minutes with patient
    HCPCS CodesHCPCS
    No codes listed
    Post-ketamine psychotherapy session limit
    Sessions covered3 post-ketamine assisted psychotherapy sessions per KAP course
    Daily limitOnly 1 session per day
    Initial integration therapy timing
    Standard timingInitial integration therapy sessions are scheduled within 1–3 days following a KAP session
    Same-day exceptionSame-day integration may be covered if clinically justified by the provider

    Provider Requirements and Coverage Risks

    Documentation Required

    Required KAP Documentation

    For each integrated session, document the therapeutic goals, session content, and progression directly related to processing the KAP experience. Also record observable outcomes across integrated sessions—including therapeutic gains, challenges, or adverse events—and the timing of the integrated therapy in relation to the KAP session.

    • Document therapeutic goals for the session.
    • Document session content.
    • Document progression directly related to processing the KAP experience.
    • Record observable patient outcomes across integrated sessions: therapeutic gains, challenges, or adverse events.
    • Record the timing of integrated therapy related to KAP.
    Denial Risk

    Coverage Criteria for Three Post-Ketamine Sessions

    Clinical Background

    Ketamine is a Schedule III controlled substance and NMDA receptor antagonist approved by the FDA as a general anesthetic. It also has rapid-acting antidepressant effects and is used off-label for treatment-resistant depression. The precise mechanism of its antidepressant effect is not established; proposed mechanisms include NMDA receptor inhibition and temporary changes in synaptic neuroplasticity, as well as effects involving cortical and limbic systems. Ketamine-assisted psychotherapy (KAP) combines ketamine administration with psychotherapy intended to process and apply insights from the ketamine experience.

    Evidence reviews suggest that combining ketamine with psychotherapy may benefit psychiatric symptoms and may help sustain or prolong treatment effects. However, studies vary substantially in diagnoses, ketamine protocols, psychotherapy methods, treatment sequencing, and study quality; evidence is therefore promising but mixed, and further robust randomized controlled trials are needed.

    Key Definitions

    Ketamine-assisted psychotherapy (KAP)
    ApproachA therapeutic approach that combines the administration of ketamine with psychotherapy sessions for depression
    Therapy purposePsychotherapy may include processing and applying insights from the ketamine experience
    Ketamine
    ClassificationSchedule III controlled substance
    MechanismNMDA receptor antagonist
    FDA-approved useGeneral anesthetic for surgeries and procedures not requiring muscle relaxation
    Other clinical effect

    Treatment Modalities

    Ketamine-assisted psychotherapy (KAP)

    Ketamine-assisted psychotherapy is covered when the treatment is delivered under the specified clinical, facility, safety, documentation, and provider-qualification requirements.

    KAP treatment criteria: Post-ketamine psychotherapy is provided in an approved University of Utah Behavioral Health credentialed clinic for a member with a qualifying diagnosis, with integration therapy scheduled within 1–3 days following a KAP session (same-day integration may be covered if clinically justified by the provider), focused on processing and applying insights from KAP, documented as required, supported by onsite safety monitoring, and delivered by a licensed mental health provider with relevant KAP or psychedelic-assisted therapy training or experience.3 post-ketamine psychotherapy sessions; maximum 1 per day

    Credentialed clinics must maintain and have available documentation of provider qualifications and KAP-specific training.

    Visit Limits

    Post-ketamine assisted psychotherapy
    Covered limit3 post-ketamine assisted psychotherapy sessions per KAP course
    Coverage conditionCovered when the listed clinic, diagnosis, timing, treatment-focus, documentation, safety-monitoring, and clinician-qualification criteria are met
    Post-ketamine assisted psychotherapy
    Daily maximum1 post-ketamine assisted psychotherapy session per day
    Applies toThe 3 covered post-ketamine assisted psychotherapy sessions
    Policy Summary
    PayerUniversity of Utah Health Plans
    PolicyKetamine-Assisted Psychotherapy (KAP)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMar 27, 2026
    Next Review DateFeb 27, 2027
    Key ActionDocument therapeutic goals, session content, KAP-related progression, gains, challenges or adverse events, and therapy timing for each integrated session.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Billing ParametersProvider Requirements and Coverage RisksClinical BackgroundKey DefinitionsTreatment ModalitiesVisit Limits

    Coverage includes three post-ketamine assisted psychotherapy sessions, limited to one session per day, only when all applicable coverage conditions are met. Failure to satisfy any required condition may result in noncoverage.

    • Treatment is provided at an approved U of U Health Plans Behavioral Health credentialed clinic.
    • The member has Major Depressive Disorder, Post-Traumatic Stress, a generalized or other anxiety disorder, or Obsessive-Compulsive Disorder.
    • Initial integration therapy is scheduled within 1–3 days following a KAP session; same-day integration may be covered when clinically justified by the provider.
    • Sessions focus on processing and applying insights from KAP.
    • Each integrated session includes the required therapeutic-goal, session-content, progression, observable-outcome, and timing documentation.
    • The clinic has an onsite qualified clinician to monitor member safety: RN, APRN, PA, or MD.
    • Integration therapy is provided by a licensed mental health provider, such as an LCSW, LPC, or LMFT, with relevant KAP or psychedelic-assisted-therapy training or experience.
    • The credentialed clinic maintains and can provide documentation of each provider’s qualifications and KAP-specific training.
    Note

    Medicaid Coverage Determination

    For Medicaid plans, coverage is determined by the State of Utah Medicaid program. If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, the U of U Health Plans Commercial criteria apply; Medicaid-covered CPT/HCPCS codes may still require additional medical-necessity review.

    • Check current Utah Medicaid policies and coverage through the Utah Medicaid official publications website or Utah Medicaid code Look-Up tool.
    • Apply Utah State Medicaid coverage policy when a published Medicaid position is available.
    • Use InterQual criteria when applicable and available.
    • If Utah Medicaid has no published coverage position and InterQual criteria are unavailable, apply U of U Health Plans Commercial criteria.
    • Do not assume that a CPT/HCPCS code covered by Utah Medicaid establishes medical necessity or guarantees coverage; further evaluation may be required.
    Has rapid-acting antidepressant effects and is used off-label for treatment-resistant depression