How do I get Spravato approved by my insurance?

Why there is a prior authorization

Spravato (esketamine) treatment involves 8 sessions in the first month. Almost every commercial and Medicare Advantage plan requires approval before the first dose. Original Medicare does not, but the clinic must still document the same criteria. Check your plan in the coverage checker and read Spravato coverage by insurer. See the Spravato overview for the treatment schedule and answers to common questions.

What the clinic submits

1. Diagnosis of major depressive disorder (or MDD with suicidal thoughts).
2. A list of antidepressants tried in the current episode with doses, dates and outcomes. Two adequate trials is the threshold.
3. Confirmation that you are on an oral antidepressant now.
4. A baseline rating scale score (PHQ-9, MADRS or HAM-D).
5. Confirmation that the clinic is REMS certified and that you have no exclusions (uncontrolled hypertension, aneurysm, pregnancy, psychosis).

What happens next

The plan's reviewer compares the submission with the written policy. Approval usually comes in 3 to 10 business days for commercial plans and up to 14 for Medicare Advantage. Approval covers the induction phase (typically 8 sessions over 4 weeks). A reauthorization with an updated score showing improvement is needed for maintenance sessions; plans commonly want a 50 percent improvement, or at least a meaningful drop. Read Maintenance for Spravato, ketamine and TMS.

Why are Spravato prior authorizations denied?

• Fewer than two documented adequate trials (the most common by far).
• No oral antidepressant on the current medication list.
• A bipolar diagnosis anywhere in the chart.
• Missing baseline score.
• Trials outside the current episode.

Fixing a denial

1. Read the denial letter for the specific criterion.
2. Ask the clinic to request a peer-to-peer call. The prescriber talks to the plan's medical director; documentation denials are often reversed on the call.
3. If needed, file a written appeal with the missing records. Commercial plans allow 180 days; Medicare Advantage 60.
4. If the internal appeal fails, request an external review by an independent reviewer. It is free and binding.

How can I speed up Spravato approval?

Send your pharmacy dispensing history to the clinic before the intake. Nothing shortens the process more. See Spravato: the complete guide and your insurer's page on the coverage hub.

My insurance denied Spravato. What can I do?

Read the denial letter for the specific criterion. Ask the clinic to request a peer-to-peer call. The prescriber talks to the plan's medical director, and documentation denials are often reversed on the call. If that fails, file a written appeal with the missing records. The most common reason is fewer than two documented adequate trials.

Read Does Medicare cover Spravato, and how much will I pay? and Treatment-resistant depression: what the criteria actually mean.