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Spravato vs. Ketamine: Are they covered?

Recently, Magellan’s Special Investigations Unit (SIU) and Payment Integrity Unit (PIU) have reported several cases that involved inappropriate billing for Spravato services and Ketamine assisted therapy.

This is a reminder that you should provide and bill only for services to members that are medically necessary and consistent with applicable regulations, policies and record-keeping standards required by law and supported by U.S. Food and Drug Administration approval and Magellan standards.

What is Spravato?

Spravato (brand name for nasal spray Esketamine) is a U.S. FDA-approved medicine for adults with treatment-resistant depression or major depressive disorder with suicidal ideation. The patient self-administers Spravato under the supervision of a healthcare provider in a certified doctor’s office or clinic, and the spray cannot be taken home. The provider instructs the patient on how to operate the nasal spray device. Adhering to prescribing information, patients who have the drug administered in the provider’s office should be monitored for two hours to assess for complications.

• The FDA approved Spravato in 2019 for use in conjunction with an oral antidepressant for the treatment of treatment-resistant depression.
• The approved administration of Spravato includes twice-weekly dosing in the earlier weeks of initiation and progresses towards once weekly or biweekly thereafter.

What are the appropriate procedure codes used for Spravato observation? 

Below are several but not all procedure codes related to Spravato observation services. Please check your fee schedule and provider contract for procedure code definitions and rates. Providers must be contracted for these codes to bill for them.* 

• 99415 – Prolonged clinical staff service, first hour
• 99416 – Prolonged clinical staff service, each additional 30 minutes
• 99417 - Prolonged physician services rendered by an MD, APRN, or PA: each additional 15 minutes code G2212. Each additional 15 minutes for Medicare Advantage members can only be billed with Evaluation & Management (E/M) codes 99205 to 99215.

What is Ketamine?

• Ketamine is not FDA-approved for the treatment of any psychiatric disorder, and FDA has not determined that Ketamine is safe and effective for such uses.
• Magellan does not cover Ketamine assisted psychotherapy (KAP) using psychotherapy procedure codes, and does not cover E/M with or without psychotherapy add-on services related to Ketamine administration.

Some things to keep in mind

• Use of Spravato requires precertification/prior authorization review.
• Providers administering Spravato must participate in the drug manufacturer’s Risk Evaluation and Management Strategy (REMS) program because of the risks of serious adverse outcomes from sedation, dissociation, abuse and misuse.
• Spravato must be administered under the direct supervision of a healthcare provider.
• Submit claims indicating the appropriate provider who was authorized and/or who rendered the service.
• Remember that Ketamine is not an FDA-approved treatment for any behavioral health or psychiatric condition. Although psychotherapy is a covered service in and of itself and will be processed according to the member’s eligibility/benefits, KAP is not a covered service. Administering Ketamine that is not FDA-approved for a behavioral health or psychiatric condition may trigger an audit/investigation by Magellan SIU or review by the Magellan PIU.

Lack of compliance with documentation standards and coding guidelines may result in a retraction of payment for the provider’s services (with overpayments referred to Magellan’s Cost Containment department for recovery); Magellan initiating mandated reporting to customer oversight agencies or a state’s fraud division; placement of the provider’s claims on pre-payment review; and possible termination from the Magellan network.

For more information

• Review Magellan's policy on audits and investigations in Section 4, page 86 of Magellan's National Provider Network Handbook (PDF).
• If you have additional questions regarding our audit/investigation processes, contact the SIU via email (SIU@MagellanHealth.com) or via our hotline, 1-800-755-0850 (you may remain anonymous).

*Spravato observation is not a covered service for some programs, including Pennsylvania HealthChoices. If you have questions about the services for which members in care are eligible, and you or your practice/organization are contracted, contact Magellan.