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
- o 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 has been completed: 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)
Key Coverage Criteria
- Spravato is medically necessary for the treatment of treatment-resistant depression (TRD) when all of the following criteria are met: Initial Therapy ... Continuation of Therapy ... Reauthorization will be for no longer than 12 months
- Spravato is medically necessary for the treatment of treatment-resistant depression (TRD) when all of the following criteria are met: Initial Therapy o Diagnosis of major depressive disorder (treatment-resistant), according to the current DSM (i.e., DSM-5-TR), by a mental health professional; and
- Spravato is medically necessary for treatment-resistant depression (TRD) when a diagnosis of major depressive disorder is confirmed, baseline scoring documented on validated scales, failure of at least two antidepressants for at least 8 weeks each, REMS program certification, psychiatrist involvement, adherence to FDA labeling, and 12-month initial authorization with possible 12-month continuation.
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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