Getting Prior Authorization for Ketamine

Prior authorization (PA) — the requirement that insurers approve a treatment before they will cover it — is a major barrier for many ketamine patients. Understanding the PA process, what documentation is required, and how to navigate it effectively can make the difference between coverage and denial.

Prior Authorization: What It Is and Why It Exists

Prior authorization is an insurer's mechanism to evaluate whether a proposed treatment meets their coverage criteria before they pay for it. For high-cost or specialized treatments, PA requirements give insurers the ability to verify medical necessity, confirm prior treatments were tried, and ensure the proposed treatment is used appropriately.

Critics argue that PA creates inappropriate barriers to medically necessary care; proponents argue it prevents unnecessary utilization of expensive treatments. Whatever the policy debate, PA is a reality for most patients seeking Spravato or other ketamine-based treatments. If your PA is denied, see our guide on how to appeal an insurance denial.

PA for Spravato (Esketamine)

Spravato is the only FDA-approved ketamine-related product with a defined, specific prior authorization pathway. Commercial insurers have PA criteria for Spravato because it is an FDA-approved specialty drug. These criteria are consistent with (though sometimes more restrictive than) the FDA-approved label. For more on coverage options, see our insurance coverage guide.

Typical Spravato PA Criteria (Commercial Insurance)

Step 1 — Diagnosis:

• Confirmed diagnosis of major depressive disorder (MDD)
• For TRD indication: Current depressive episode documented with validated rating scale (usually PHQ-9 ≥10 or MADRS ≥20)
• For MDD-SI indication: Documented active suicidal ideation with intent or behavior

Step 2 — Prior Treatment Failures:

• Documentation of at least 2 antidepressant trials of adequate dose and duration in the current episode
• Required information for each trial:
  • Specific drug name
  • Dose prescribed
  • Duration of treatment
  • Reason for discontinuation (inadequate response, intolerance, patient preference)

Step 3 — Concurrent Oral Antidepressant:

• Patient must be taking or starting an oral antidepressant concurrently with Spravato
• Name and dose of the oral antidepressant

Step 4 — Provider/Facility:

• Prescribing provider must be licensed and appropriate specialty (psychiatrist preferred)
• Administering facility must be enrolled in the Spravato REMS

Step 5 — Additional Requirements (Payer-Specific):
Some payers additionally require:

• Documentation of augmentation strategy trials (lithium, atypical antipsychotic added to antidepressant)
• Specialist consultation note
• Minimum baseline PHQ-9 or MADRS score

Documents to Prepare for Spravato PA

Compile the following before submitting:

1. Prescriber letter of medical necessity: Comprehensive letter documenting diagnosis, treatment history, rationale for Spravato, and treatment plan (see structure below)
2. Psychiatric records: Clinical notes documenting the diagnosis, severity, and treatment course
3. Medication history: Pharmacy or prescriber records listing all antidepressant trials with dates, doses, and reasons for discontinuation
4. Validated rating scale results: Current PHQ-9 or MADRS with score and date
5. Plan for concurrent oral antidepressant: Name of the antidepressant patient will take with Spravato
6. REMS certification documentation: Confirmation that the administering facility is REMS-enrolled

Writing an Effective Letter of Medical Necessity

The letter of medical necessity is the most important document in the PA package. An effective letter includes:

Patient identifiers: Name, date of birth, member ID

Diagnosis: Specific DSM-5 diagnosis codes (e.g., F33.2: Major depressive disorder, recurrent severe)

Clinical history: Duration of illness, severity, functional impairment (work, relationships, quality of life)

Specific prior treatment trials (enumerate each one):

• Drug A: [Name], [dose], [duration], [response], [reason discontinued]
• Drug B: [Name], [dose], [duration], [response], [reason discontinued]
• Drug C (if augmentation): [Name + augmenter], [dose], [duration], [response]

Why Spravato is medically necessary:

• Explain the clinical urgency (risk of suicide, severe functional impairment)
• Explain why continuing to try conventional antidepressants is inappropriate or unlikely to succeed
• Reference relevant clinical literature if helpful

Treatment plan: Number of sessions, concurrent antidepressant, monitoring plan

Clinical judgment statement: The prescriber's professional judgment that this patient meets criteria for Spravato and that the risks are acceptable given the clinical situation

PA for Off-Label Ketamine Tablet

Getting prior authorization for compounded ketamine tablet for psychiatric indications is more difficult because:

1. No FDA approval exists for this use
2. Compounded preparations are typically excluded from formularies
3. Few insurers have established PA policies for compounded ketamine tablet

Realistic expectations: For compounded ketamine tablet psychiatric uses, PA approval is uncommon. The most common outcome is denial, which can then be appealed.

For pain indications, PA is more achievable: Some insurers have policies covering ketamine for specific pain conditions (particularly CRPS). The same documentation framework applies — diagnosis, prior treatment failures, rationale for ketamine — but submitted under a pain management rather than psychiatric framework.

Step-by-Step PA Submission Process

Step 1: Identify the Correct PA Pathway

Call your insurer's provider services line (the number on your insurance card) and ask:

• Do you have a coverage policy for Spravato or esketamine?
• How is this covered — under pharmacy benefit or medical benefit?
• Who is the PA department I should submit to?

Step 2: Gather Required Documentation

Compile all documents listed above. Incomplete submissions are the most common reason for unnecessary denials.

Step 3: Submit the PA Request

Submit to the appropriate department:

• For Spravato: Often submitted through the specialty pharmacy or the REMS-enrolled facility
• For off-label ketamine tablet: Submitted through the prescriber's office or directly to the insurer's PA department

Follow up within 3–5 business days to confirm receipt.

Step 4: Know the Timeline

Most insurers are required by regulation to make PA decisions within:

• Standard: 14 calendar days of receiving the complete request
• Urgent/expedited: 72 hours if the prescriber certifies that a standard review timeline could seriously jeopardize patient health

If a decision is not received within the regulatory timeframe, contact your state insurance commissioner.

Step 5: Respond to Requests for Additional Information

Insurers frequently request additional documentation. Respond promptly and completely. Delays in responding extend the timeline.

Peer-to-Peer Review

If initial PA is denied or appears likely to be denied, your prescriber can request a peer-to-peer review — a telephone conversation between your prescriber and the insurer's reviewing physician.

This is often the most effective intervention for overturning a borderline denial, because:

• It allows your prescriber to present the clinical case directly
• It bypasses the bureaucratic review process
• The insurer's physician may have a different perspective than the initial reviewer
• It demonstrates the clinical urgency of the situation

Request peer-to-peer review immediately if you receive a denial or if you are told a denial is forthcoming.

If Your PA Is Denied

A denial is not final. Successful appeals of initial PA denials are common for Spravato. See our detailed insurance appeals article for the full appeal process.

The key steps are:

1. Get the denial reason in writing
2. Address specific denial reasons in your appeal
3. Submit additional supporting documentation
4. Request peer-to-peer review if not yet completed
5. Escalate to external appeal if internal appeal fails

References

• StatPearls: Ketamine — Comprehensive clinical reference on ketamine pharmacology, mechanisms of action, and therapeutic applications
• PubChem: Ketamine Compound Summary — NCBI chemical database entry with ketamine molecular data, pharmacokinetics, and bioactivity profiles
• MedlinePlus: Ketamine — National Library of Medicine consumer drug information on ketamine including uses, proper administration, and precautions
• NIMH: Depression — National Institute of Mental Health overview of depressive disorders, treatment-resistant forms, and emerging therapies
• WHO: Depression Fact Sheet — World Health Organization global data on depression prevalence, burden, and treatment approaches