How to Get Ketamine Infusions Covered by Insurance

Ketamine infusions are a promising treatment for severe depression and post-traumatic stress disorder when traditional therapies have not provided relief. Navigating insurance coverage for these infusions can be challenging. This article guides individuals through the process of seeking coverage.

Understanding Ketamine Infusion Coverage Landscape

Insurance coverage for ketamine infusions is difficult because intravenous ketamine’s use for mental health conditions is considered “off-label.” While FDA-approved as an anesthetic, its psychiatric application is not specifically approved, making insurers hesitant. This contrasts with esketamine (Spravato), a ketamine derivative, which received FDA approval in 2019 and a supplemental approval in 2025 for treatment-resistant depression (TRD) and depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior. Esketamine is more likely to be covered due to its FDA-approved status.

Insurers require specific criteria before approving coverage. These include:
Demonstrating medical necessity.
Showing that traditional treatments have failed.
Providing evidence-based support for the proposed therapy.
Medical necessity refers to healthcare services or supplies needed to diagnose or treat an illness, injury, condition, or disease that meet accepted medical standards. Coverage for ketamine infusions is highly variable, depending on the specific insurance plan, state regulations, and the insurer’s interpretation of medical necessity and evidence.

Preparing Your Coverage Inquiry

Before initiating any formal process with your insurance provider, gather comprehensive information and documentation. Collect all relevant policy information, including your policy number, group number, plan name, and contact details for both mental health and medical benefits departments. Understanding your specific plan’s benefits is crucial for determining potential coverage.

Obtaining thorough medical documentation from your treating physician is essential. This documentation should include diagnosis codes (e.g., ICD-10 for Major Depressive Disorder) and procedure codes (e.g., CPT 96365 for initial hour, 96366 for additional hours). A history of previous treatments and why they failed to provide relief is necessary to demonstrate medical necessity, often requiring documentation of two to three failed conventional treatments.

Also obtain the ketamine infusion clinic or provider’s billing information, including their National Provider Identifier (NPI) and any relevant certifications. When contacting your insurer, ask:
Whether ketamine infusion for your diagnosis is covered.
What medical necessity criteria must be met.
If prior authorization is required.
Document every interaction, noting names of representatives, dates of calls, and reference numbers.

Navigating the Prior Authorization Process

Prior authorization is an insurer requirement, mandating approval before certain medical services or medications. This process assesses the medical necessity and cost-effectiveness of a proposed treatment. For ketamine infusions, the treating provider or clinic initiates the prior authorization request on your behalf.

Providers submit these requests through online portals, fax, or phone. Documentation includes a letter of medical necessity from the treating physician, a history of your treatment, clinical notes, and peer-reviewed literature supporting ketamine’s efficacy for your condition.

Response times for prior authorization requests vary. Standard requests receive a response within 1 to 3 business days, while urgent requests are processed within 24 to 72 hours. Complex cases or those requiring additional information can extend the timeline to several weeks. Both patient and provider should follow up on the request status to avoid delays. If approved, the authorization specifies the number of sessions or duration of coverage; a denial letter outlines the reasons and appeal instructions.

Appealing a Denied Claim

If prior authorization for ketamine infusions is denied, or a claim rejected, understanding the appeals process is important. Review the denial letter, as it specifies the reasons (e.g., “not medically necessary,” “experimental,” “lack of sufficient documentation”). Identifying the reason is important for crafting an effective appeal.

The first step in challenging a denial is to file an internal appeal with your insurance company. This asks the insurer to review their decision. The appeal submission should include a letter of medical necessity from your provider, along with additional supporting evidence, such as updated clinical notes or documentation of failed traditional treatments. Your provider may engage in a peer-to-peer review with the insurer’s medical reviewer. Adhering to deadlines, often 60 to 180 days from the denial date, is important for internal appeals.

If internal appeals are unsuccessful, you can seek an independent external review. This process involves an independent medical expert, unaffiliated with your insurer, reviewing your case and making a binding decision. External reviews are available after exhausting the internal appeals process. Documenting all communications, submissions, and decisions throughout both internal and external appeal processes is important for a comprehensive record.

Exploring Financial Alternatives

When insurance coverage for ketamine infusions is not secured or out-of-pocket costs remain substantial, several financial alternatives can help. Many ketamine clinics offer structured payment plans, allowing patients to spread the cost of treatment over time. Inquiring about these options directly with the clinic can make treatment accessible.

Various non-profit organizations and foundations offer patient assistance programs or grants for mental health treatments, including ketamine therapy. While less common for intravenous ketamine due to its off-label status, explore these resources. For FDA-approved esketamine, pharmaceutical company programs may be available.

Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) provide a means to pay for qualified medical expenses with pre-tax dollars. Funds contributed to an HSA or FSA cover out-of-pocket medical costs, including deductibles, copayments, and services not fully covered. Utilizing these accounts reduces financial burden through tax advantages.

Explore participation in clinical trials related to ketamine or similar novel treatments. Clinical trials offer treatment at reduced or no cost, providing access while contributing to medical research. Some clinics may offer discounted cash prices for uninsured or underinsured patients, a valuable option for those paying entirely out-of-pocket.