Medicare and Medicare Advantage Coverage Policies for Ketamine Therapy Dataset 2025
A comprehensive compilation of Medicare and Medicare Advantage coverage policies across major carriers documenting their approaches to Spravato, IV ketamine, IM ketamine, and oral ketamine therapy coverage.
This dataset includes detailed policy analysis, prior authorization requirements, site-of-care restrictions, and exclusion criteria for ketamine-based treatments across CMS national policies, Medicare Administrative Contractors (MACs), Medigap policies, and major Medicare Advantage carriers.
Who This Dataset Is For
Built for reporters, researchers, healthcare advocates, and care coordination teams who need clean, documented, downloadable data on ketamine therapy coverage policies across Medicare and Medicare Advantage plans. Essential for understanding coverage variability, identifying access barriers, analyzing prior authorization requirements, and tracking policy changes across different ketamine therapy modalities.
Independent & Non-Commercial
This website carries no ads, sponsorships, affiliate links, or paid placements. We have no financial ties to anyone.
Verified Methodology
We derived plan size and rank from CMS source files only. Specifically, we used the August 2025 Monthly Enrollment by Contract extract and limited the dataset to Medicare Advantage organization types (Local CCP, Regional CCP, PFFS, MSA), excluding PDP-only records. Where the contract extract exposed a Parent Organization field, we aggregated enrollment to that field; where necessary, we confirmed or supplemented the mapping by joining to the August 2025 MA Plan Directory on contract identifier. Contract identifiers were standardized, enrollment counts were converted to integers, and total covered lives were summed by parent organization. We then calculated market_share_pct as the parent’s covered lives divided by the total Medicare Advantage enrollment in the same monthly extract, and constructed cumulative_share_pct by ordering parents from largest to smallest and computing the running total. Results were compared with an external reference (KFF’s 2025 summary of the top five parent groups) to confirm directional alignment, noting that differences can arise from using different months. All outputs were produced directly from CMS files without third-party estimates or imputation; records lacking a resolvable parent mapping were excluded rather than inferred.
What You’re Downloading
Scope: This dataset covers ketamine therapy coverage policies across CMS National, Medicare Administrative Contractors (MACs), Medigap policies, and major Medicare Advantage carriers. Includes detailed policy analysis for four ketamine therapy types: Spravato (SPR), IV Ketamine (IVK), IM Ketamine (IMK), and Oral Ketamine (ORK). Dataset created September 3, 2025, with verification dates ranging from September 1-2, 2025.
Data Dictionary
Type of Medicare organization (CMS_National, MAC_Contractor, CMS_Medigap, Carrier_Policy, parent_group)
Parent organization or contractor name (CMS, Noridian, NGS, Palmetto, Novitas, WPS, carrier names)
Specific plan or jurisdiction name (e.g., “CMS Original Medicare”, “Jurisdiction JE”, specific plan names)
Type of Medicare coverage (Medicare, Medigap, Medicare Advantage)
Geographic coverage area (states, regions, or “All States”)
Market share percentage for Medicare Advantage plans (when applicable)
Cumulative market share percentage (when applicable)
Direct URL to the coverage policy or policy database
Title or description of the coverage policy
Date when the policy was last updated by the carrier
Date when the policy information was last verified for this dataset
Coverage status for Spravato (esketamine) therapy
Approved indications for Spravato coverage
Whether prior authorization is required for Spravato
Step therapy requirements for Spravato coverage
Prescriber requirements or restrictions for Spravato
REMS (Risk Evaluation and Mitigation Strategies) requirements for Spravato
Required monitoring time periods for Spravato administration
Required or preferred site of care for Spravato administration
Benefit channel (Medical or Pharmacy) for Spravato coverage
Supply model requirements for Spravato (e.g., specialty pharmacy)
Relevant CPT/HCPCS codes for Spravato billing
Reason for Spravato exclusion from coverage (if applicable)
Direct quote from policy document regarding Spravato coverage
Coverage status for IV ketamine therapy
Reason for IV ketamine exclusion from coverage (if applicable)
Direct quote from policy document regarding IV ketamine coverage
Coverage status for IM (intramuscular) ketamine therapy
Reason for IM ketamine exclusion from coverage (if applicable)
Direct quote from policy document regarding IM ketamine coverage
Coverage status for oral ketamine therapy
Reason for oral ketamine exclusion from coverage (if applicable)
Direct quote from policy document regarding oral ketamine coverage
Reference to specific document section or database searched
Note: Fields marked as “Not_Stated” indicate that specific information was not available or stated in the policy documents reviewed. Coverage status analysis shows 13 policies with Spravato coverage information, 8 with IV ketamine information, 4 with IM ketamine information, and 3 with oral ketamine information out of 40 total records.
Data Preview
Scroll horizontally to see all columns. Full dataset in the download.
| entity_type | parent_group | brand_plan | line_of_business | geography | policy_title | SPR_status | IVK_status | IMK_status | ORK_status |
|---|---|---|---|---|---|---|---|---|---|
| CMS_National | CMS | CMS Original Medicare | Medicare | All States | No National Coverage Determination for Ketamine Therapy | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Noridian | Jurisdiction JE | Medicare | CA, NV, HI, AS, GU, MP | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Noridian | Jurisdiction JF | Medicare | AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | NGS | Jurisdiction J6 | Medicare | IL, MN, WI | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | NGS | Jurisdiction JK | Medicare | CT, MA, ME, NH, NY, RI, VT | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Palmetto | Jurisdiction JJ | Medicare | AL, GA, TN | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Palmetto | Jurisdiction JM | Medicare | NC, SC, VA, WV | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Novitas | Jurisdiction JL | Medicare | DE, DC, MD, NJ, PA | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | Novitas | Jurisdiction JH | Medicare | AR, CO, LA, MS, NM, OK, TX | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
| MAC_Contractor | WPS | Jurisdiction J5 | Medicare | IA, KS, MO, NE | No LCD/LCA specific to ketamine or Spravato | Not_Stated | Not_Stated | Not_Stated | Not_Stated |
← Scroll left and right to see all columns →
✅ Quality Controls
Source Verification: All policy information verified directly from carrier websites and official policy documents between September 1-2, 2025
Coverage Standardization: Consistent categorization across four ketamine therapy types (Spravato, IV, IM, Oral) with standardized status fields
Geographic Completeness: Coverage includes all Medicare Administrative Contractors (MACs) and major Medicare Advantage carriers across all US states and territories
Policy Documentation: Direct quotes from policy documents included where available, with clear distinction between “Not_Stated” and actual exclusions
Download The Medicare and Medicare Advantage Ketamine Therapy Coverage Policies Dataset 2025
There are 2 Separate Data Files:
medicare_and_medicare_advantage_ketamine_therapy_coverage_policies.csv: This dataset shows 2025 Medicare Advantage enrollment by parent organization. Each row lists a carrier, the number of covered lives in its MA products, its share of the national MA market, and the cumulative share when ranked from largest to smallest. Source fields document whether the figure comes from KFF’s July 2025 national enrollment update or from CMS’s August 2025 Monthly Enrollment by Contract file.
Version 1.0.0 — Last updated: September 3, 2025
Zenodo DOI: 10.5281/zenodo.17049243
medicare_advantage_market_share_enrollment_by_carrier.csv: This file reports 2025 Medicare Advantage enrollment by parent organization. Each row lists the parent group, covered lives (MA only), market_share_pct, and cumulative_share_pct in rank order, along with source_url/source_title/source_date and last_verified fields indicating whether figures come from KFF’s July 2025 national update or CMS’s August 2025 Monthly Enrollment by Contract.
Version 1.0.0 — Last updated: September 2, 2025
Zenodo DOI: 10.5281/zenodo.17049285
Download Agreement
By downloading you agree to cite “Michael Alvear” and link back to this page: https://ketaminetherapyfordepression.org/datasets/medicare-and-medicare-advantage-coverage-policies
Required Attribution
About the author: Independent researcher/patient advocate focused on healthcare costs and access.
How to Cite
BibTeX and other formats available after Zenodo download
Quick Usage Examples
- Compare Spravato coverage policies across Medicare Advantage carriers by geography
- Analyze prior authorization requirements for different ketamine therapy modalities
- Identify coverage gaps and access barriers for ketamine-based treatments
- Research site-of-care restrictions and benefit channel variations across carriers
Technical Details
File Access
- Opens in Excel, Google Sheets, or any data tool
- UTF-8 encoding, comma-separated values
- No macros or executable content
- Served over HTTPS with file hash verification
Import Instructions
- Excel: Import as UTF-8, comma-separated
- Google Sheets: File → Import → Upload
- Python:
pd.read_csv('file.csv')
⚠️ Known Limitations
- Information reflects published data as of the “Last updated” date
- This is not an official government site
- Policy details may vary by specific plan within parent organizations
⚖️ License & Usage
CC BY 4.0: Free to use, modify, and redistribute with attribution
This dataset is for educational and operational planning—not medical or legal advice.
Corrections & Updates
See something that needs fixing? Help improve this dataset for everyone.
Email us with the state name, column, and suggested correction. We review and update with attribution in the changelog.
Update Schedule
We aim to review correction requests within 7 business days and publish updates monthly or sooner when critical changes are reported.