Does Original Medicare have a posted coverage policy for Spravato or other ketamine routes?

No. As verified on August 31, 2025, Original Medicare and all regional MACs are “Not Stated” for esketamine and for IV, IM, and oral/sublingual ketamine. Claims are typically handled case-by-case.

What does “Not Stated” mean in practice?

Policy silence usually behaves like non-coverage unless an exception is won through medical-necessity review, appeals, or peer-to-peer. It increases delays and abandonment risk.

Are off-label ketamine routes like IV, IM, and oral covered more or less often than Spravato?

Less often. Off-label routes are overwhelmingly “Not Stated,” with meaningful explicit exclusions—especially IV—making access harder than for esketamine.

Do billing codes G2082 and G2083 guarantee Medicare coverage?

No. Codes enable billing for esketamine visits but do not establish coverage. Without an affirmative policy, decisions are reviewer- and documentation-dependent.

What can beneficiaries or clinics do when the policy is “Not Stated”?

Prepare medical-necessity packets, request case review, and escalate denials. Prefer MA plans with posted route-specific policies where possible.

Who Can Get Ketamine Therapy Under Medicare?

Name: Medicare and Medicare Advantage Coverage Policies for Ketamine Therapy (Route-Specific, Aug 2025)
Creator: Michael Alvear
License: https://creativecommons.org/licenses/by/4.0/

This study analyzed written coverage positions for esketamine (Spravato) and other ketamine routes (IV, IM, oral) across Original Medicare (national program), all regional Medicare Administrative Contractors (MACs), and Medicare Advantage (MA) parent groups, enrollment-weighted to August 2025 (30,786,085 MA lives).

What This Study Found

Across Original Medicare and all Medicare Administrative Contractors, coverage status for every ketamine route—Spravato (esketamine), IV, IM, and oral/sublingual—is “Not Stated.” That means claims default to case-by-case review despite existing G-codes for Spravato visits. In Medicare Advantage (30.8M lives, Aug 2025), an enrollment-weighted 36.5% (≈11.3M) are in plans that explicitly cover Spravato (≈33.5% with prior authorization; ≈3.1% without). The remaining 63.5% (≈19.5M) fall under “Not Stated,” which in practice behaves like non-coverage unless an exception is won. Off-label routes are more restricted: IV Not Stated 87.5% with 12.5% explicit exclusions; IM Not Stated 91.8% with 8.2% exclusions; oral/sublingual Not Stated 98.3% with 1.7% exclusions. The net effect: coverage clarity—not billing codes—predicts who gets timely access. :contentReference[oaicite:1]{index=1}

Why It Matters

For patients with treatment-resistant depression, policy silence slows or blocks a fast-acting therapy. Under “Not Stated,” clinics must assemble medical-necessity packets and fight denials, stretching time-to-first-dose and increasing abandonment. In Medicare Advantage, even where coverage exists, prior authorization adds forms, peer-to-peer calls, and scheduling delays that can disrupt the FDA-labeled cadence. For those who cannot use nasal spray, access drops further: IV/IM/oral pathways are rarely posted and sometimes explicitly excluded. Bottom line for patients and clinicians: plan logo and paperwork capacity often determine access more than clinical need. :contentReference[oaicite:2]{index=2}

Methods in Brief

Cross-sectional policy mapping of Original Medicare (national), all MAC jurisdictions, and Medicare Advantage parent groups. MA results are enrollment-weighted to August 2025 (30,786,085 lives) to reflect lived exposure. Sources include official payer PDFs/HTML policy portals, CMS HCPCS references (G2082, G2083), and an MA market-share file. Each row records route-specific status (Covered; Covered with PA; Not Stated; Excluded) plus verification date and citation snippet. Canonical sources: CMS/Medicare policy portals and insurer clinical policy pages; verification through August 31, 2025. Limitation: policies describe intent, not every downstream claim; benefits and riders can vary by plan. :contentReference[oaicite:3]{index=3}

Limitations & How to Interpret

Point-in-time snapshot (verified Aug 31, 2025); large carriers can shift exposure with a single update. Posted policies can lag internal guidance, and “Not Stated” invites reviewer discretion that may diverge from the public record. State riders and individual plan documents may narrow or expand access beyond parent-level texts. Treat “Not Stated” as a practical hurdle: approvals may happen, but usually only after structured case review. :contentReference[oaicite:4]{index=4}

Data & Materials

DOI (white paper): https://zenodo.org/records/17113303
Zenodo dataset DOIs: 10.5281/zenodo.17049243; 10.5281/zenodo.17049285
Wikidata item: Q136260128
License: Creative Commons Attribution 4.0 International. Last verified: 2025-09-13.
Dataset download: Dataset page

How to Cite

Alvear, M. (2025, September). Who Can Get Ketamine Therapy Under Medicare? A Route-Specific Analysis of Coverage Across Original Medicare, MACs, and Medicare Advantage. Zenodo. https://zenodo.org/records/17113303

FAQ

Does Medicare cover Spravato (esketamine) for depression?

Original Medicare and every MAC show “Not Stated” for Spravato as of August 31, 2025. In Medicare Advantage, about one in three members is in a plan with a posted Spravato path, usually requiring prior authorization. That means many beneficiaries face default denials or long delays unless their care team wins case-by-case approval. If your plan shows a posted policy, timelines improve but you’ll still need documentation and, often, a peer-to-peer review. In practice, plan transparency—not just the existence of billing codes—drives time-to-first-dose.

Takeaway: Check your plan’s written Spravato policy and be prepared for prior authorization; “Not Stated” usually functions like “no” until an exception is granted. :contentReference[oaicite:5]{index=5}

What does “Not Stated” mean for my chances of getting treated?

“Not Stated” means your plan hasn’t posted an affirmative coverage rule for that route. Most plans treat unlisted therapies as not covered unless you win a medical-necessity review. Expect requests for past treatment history, diagnosis confirmation, and a monitoring plan from a REMS-certified clinic. Approvals can happen, but they hinge on paperwork and persistence. Because criteria aren’t published, reviewers may change what they ask for mid-process, adding time and uncertainty.

Takeaway: Under “Not Stated,” assume you need a full case file and an appeals path; line up a clinic that routinely handles prior auth and peer-to-peer calls. :contentReference[oaicite:6]{index=6}

If I can’t use the nasal spray, what are my options under Medicare?

Off-label routes face steeper barriers. In Medicare Advantage, IV is 87.5% “Not Stated” with 12.5% explicit exclusions; IM is 91.8% “Not Stated” with 8.2% exclusions; oral/sublingual is 98.3% “Not Stated” with 1.7% exclusions. Original Medicare and all MACs are “Not Stated” for all routes. Clinically appropriate alternatives may still be pursued via exception, but approvals are uncommon without robust documentation and experienced utilization management.

Takeaway: If nasal spray isn’t an option, expect tougher access; talk with a clinic that can mount strong medical-necessity and exception requests. :contentReference[oaicite:7]{index=7}

How can I improve my chances of getting Spravato approved?

Start by obtaining your plan’s written policy (or confirmation that it’s “Not Stated”). Work with a REMS-experienced clinic to pre-assemble: diagnosis and TRD history, prior treatment failures, safety/monitoring plan, and justification tied to labeled indications. If coverage is posted with prior authorization, submit exactly what the policy lists. If “Not Stated,” file a medical-necessity request and be ready for peer-to-peer review and appeal timelines.

Takeaway: Documentation discipline and a clinic that handles PA/end-to-end appeals are the best predictors of approval speed. :contentReference[oaicite:8]{index=8}

About the Author

Author: Michael Alvear
Contact: [email protected]
ORCID: https://orcid.org/0009-0003-3845-418X
Last reviewed: 2025-09-13