094 Form

Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions Prior Authorization Request Form

Medical Policy #087 Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for for Esketamine Nasal Spray (Spravato TM) and Intravenous Ketamine for Treatment-Resistant Depression must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Esketamine Nasal Spray (Spravato) and Intravenous Ketamine (094) using Authorization Manager.

For out of network providers: Requests should still be faxed to 1-888-641-5199.

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Treatment Start Date: Date of Birth:

Place of Service: Outpatient  Inpatient 

Servicing Physician Servicing Facility Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#:  This is a secure fax line

 This is a secure fax line

NPI / TIN#: NPI / TIN#:

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   Check if the servicing physician is billing entity

   Check if the servicing facility is billing entity
   Check if the servicing physician is REMS certified

   Check if the servicing facility is REMS certified
   Check if Esketamine (Spravato) will be dispensed by specialty pharmacy

  Referring provider if different from servicing provider:

  Name _ Phone __

  For Esketamine and IV Ketamine requests for TREATMENT RESISTANT DEPRESSION:
  Initial requests are authorized for up to 28 days - Number of treatment session requested: __ Esketamine (Spravato) Nasal Spray:  Intravenous Ketamine:   Individual is 18 or over,  Individual meets the (DSM-5) criteria for a major depressive episode (See Table 1 in medical policy #087) by a structured clinical interview for DSM-5 disorders,  Current depressive episode is severe depression based on either of the following: a. Montgomery-Asberg Depression Rating Scale (MADRS) ≥ 28 OR b. Hamilton Rating Scale for Depression (HAM-D) score ≥ 17 AND,  Individual has had an inadequate response to four antidepressant agents from at least: • Four antidepressant agents from at least 2 or more different antidepressant classes (i.e. selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, bupropion, or mirtazapine) AND • at least one trial of augmenting agent (i.e. atypical antipsychotic, lithium, or thyroid hormone T3 Please list all medications trialed and failed:

  *An adequate trial of an antidepressant is defined by BOTH of the following: a. The trial length was at least 6 weeks at generally accepted doses or of sufficient duration as determined by the treating physician at the generally accepted doses; AND the Individual was ≥80% adherent to the agent during the trial; AND  Individual is to receive Esketamine Nasal Spray or Intravenous Ketamine in conjunction with an oral antidepressant,
   Individual does not have any of the following:
  a. Current substance use disorder unless in remission (for example, complete abstinence for one month) b. Hypersensitivity to esketamine, ketamine, or any of the excipients c. Previous treatment that was determined not to reduce symptoms or be efficacious d. Current episode of delirium
  e. Not currently pregnant or breastfeeding f. Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation g. Intracerebral hemorrhage, AND  For Esketamine (SpravatoTM) nasal spray only, the individual must NOT have any Food and Drug Administration (FDA) labeled contraindications. Esketamine (SpravatoTM) nasal spray is intended to be used consistently with the FDA approved label including meeting Spravato Risk Evaluation and Mitigation Strategy (REMS) program requirements AND, The prescriber is a specialist in the area of the patient’s diagnosis (e.g. psychiatrist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND,  Administration of Esketamine (Spravato) or Intravenous Ketamine is to occur in a provider’s office or hospital setting and must be monitored by a specialist in the area of a patient’s diagnosis (e.g., psychiatrist), OR

  Request for reauthorization after initial therapy. Requests will be authorized for up to 1 year when the following conditions are met: Esketamine (Spravato) Nasal Spray:  Intravenous Ketamine: 

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  Number of treatment session requested: __  Individual has had improvement in depression symptoms as evaluated with an appropriate depression rating scale (e.g. Patient Health Questionnaire ‐9, Clinically Useful Depression Outcome Scale, Quick Inventory of Depressive Symptomatology‐Self Report 16 Item, MADRS, HAM‐D) AND  Individual is to receive Esketamine Nasal Spray or Intravenous Ketamine in conjunction with an oral antidepressant AND  Individuals with substance use disorder have remained in remission (complete abstinence) AND  Individual does NOT develop any FDA labeled contraindications to esketamine nasal spray including aneurysmal vascular disease, intracerebral hemorrhage, or hypersensitivity to Esketamine, ketamine or any of the excipients. Use of Esketamine is intended to be used consistently with the FDA approved label including meeting Spravato REMS program requirement.
   Administration of Esketamine (Spravato) or Intravenous Ketamine is to occur in a provider’s office or hospital setting and must be monitored by a specialist in the area of a patient’s diagnosis (e.g., psychiatrist)

  For Esketamine or IV Ketamine requests for MAJOR DEPRESSIVE DISORDER WITH ACUTE SUICIDAL IDEATION:
  Esketamine (Spravato) Nasal Spray:  Intravenous Ketamine:  Initial requests are authorized for up to 28 days - Number of treatment session requested: __  Individual is 18 or over,  Individual is currently hospitalized and is at an imminent risk for suicide as documented by: a. Individual response to a structured assessment for suicidal ideation indicative of imminent risk of suicide (see policy guidelines) AND, b. Confirmation of imminent risk of suicide by clinical assessment by a mental health professional/psychiatrist (see policy guidelines)  Individual current depressive episode is moderate or severe based on either of the following scales: c. Montgomery-Asberg Depression Rating Scale (MADRS) ≥ 28 OR,
  d. Hamilton Rating Scale for Depression (HAM-D) score ≥ 17*  Individual is to receive Esketamine (SpravatoTM) nasal spray or IV Ketamine in conjunction with standard-of-care treatment based on clinical judgment and practice guidelines that may be comprised of oral antidepressant(s), an atypical antipsychotic, or a mood stabilizer.  Individual does NOT have any U.S. Food and Drug Administration (FDA) labeled contraindications to the requested agent and esketamine nasal spray is intended to be used consistently with the FDA approved label (see policy guidelines) including meeting Spravato Risk Evaluation and Mitigation Strategy (REMS) program requirements (see policy guidelines).  The prescriber is a specialist in the area of the patient’s diagnosis (e.g. psychiatrist) or the prescriber has consulted with a specialist in the area of th e patient’s diagnosis.

  CPT Codes/ HCPCS Codes/ ICD Codes for Esketamine only (for IV Ketamine see BH and SUD Payment Policy)

  HCPCS codes Code Description  G2082 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation  G2083 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation

  Providers should enter the relevant diagnosis code(s) below:

  Code Description  F33.2 Major Depressive Disorder, Severe