J0013 — Esketamine, nasal spray, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Submission of medical records (e.g., chart notes, laboratory values) documenting baseline scoring (prior to starting Spravato) on at least one of the following clinical assessments: Beck Depression Inventory (BDI); Hamilton Rating Scale for Depression (HAMD); Montgomery-Asberg Depression Rating Scale (MADRS); 9-item Patient Health Questionnaire (PHQ-9); Quick Inventory of Depressive Symptomatology (QIDS).
- History of failure of a trial of at least two different antidepressants or treatment regimens for a duration of at least 8 weeks each (document medication, date, and duration of trial). An antidepressant or treatment regimen would include classes or combinations such as SSRIs, SNRIs, bupropion, tricyclic antidepressants, mirtazapine, MAOIs, serotonin modulators, or augmentation with antipsychotics, lithium, or thyroid hormone.
- For Continuation of Therapy: Submission of medical records documenting baseline and recent (within the last month) scoring on at least one of the following assessments demonstrating remission or clinical response (e.g., score reduction from baseline) as defined by the BDI, HAMD, MADRS, PHQ-9, or QIDS.
Key Coverage Criteria
- Spravato (esketamine) nasal spray — Treatment-Resistant Depression (TRD): Spravato is proven for the treatment of treatment-resistant depression (TRD) when all of the following criteria are met: Initial Therapy: Diagnosis of major depressive disorder (treatment-resistant); and Patient has not experienced a clinically meaningful improvement after treatment with at least two different antidepressants; and Provider and/or the provider's healthcare setting is certified in the Spravato REMS program; [...]
- Spravato (esketamine) nasal spray — TRD (Medical Necessity criteria): Initial Therapy: Diagnosis of major depressive disorder (treatment-resistant), according to the current DSM (i.e., DSM-5-TR), by a mental health professional; and Submission of medical records documenting baseline scoring (prior to starting Spravato) on at least one of the following clinical assessments (Beck Depression Inventory (BDI); Hamilton Rating Scale for Depression (HAMD); Montgomery-Asberg Depression Rating Scale (MAD [...]
- Spravato (esketamine) nasal spray — Continuation of Therapy for TRD: Documentation of remission or a positive clinical response to Spravato therapy; and Provider and/or the provider's healthcare setting is certified in the Spravato REMS program; and Prescribed by or in consultation with a psychiatrist; and Spravato dosing is in accordance with the United States FDA approved labeling; and Reauthorization will be for no longer than 12 months.
- Spravato (esketamine) nasal spray — Depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior: Spravato is proven for the treatment of depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior when all of the following criteria are met: Initial Therapy: Diagnosis of major depressive disorder; and Patient is experiencing an acute suicidal ideation or behavior; and Provider and/or the provider's hea [...]
- Spravato (esketamine) nasal spray — MDD with acute suicidal ideation or behavior (Medical Necessity criteria): Initial Therapy: Diagnosis of major depressive disorder according to the current DSM (i.e., DSM-5-TR), by a mental health professional; and Patient is experiencing an acute suicidal ideation or behavior; and Patient is to receive Spravato therapy in conjunction with a newly initiated or optimized oral antidepressant; and Provider and/or the provider's healthcare setting is certified in [...]
- Ketalar (ketamine) injection — Anesthesia indications: Ketamine injection is considered medically necessary and may be covered for the following: Anesthesia for diagnostic and surgical procedures that do not require skeletal muscle relaxation; The induction of anesthesia prior to administration of other anesthesia agents; As supplemental anesthesia for low-potency agents, such as nitrous oxide.
3 Active Policies
UHC-POL-ketalar-spravato — Ketalar (Ketamine) and Spravato (Esketamine)
UMR-POL-UMR-ketalar-spravato — Ketalar (Ketamine) and Spravato (Esketamine)
SUREST-POL-SUREST-ketalar-spravato — Ketalar (Ketamine) and Spravato (Esketamine)
Related Codes
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