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Policy Name: Use of Injectable Ketamine (Ketalar) for Treatment of Mental Health Conditions
Current Policy Effective Date: November 1, 2014
Product Application
The policy applies to all fully insured Medica Health Plans, Medica Insurance Company, and Medica Health Plans of Wisconsin products,
unless a specific limitation or exception exists. For self-insured plans, consult individual plan sponsor benefit documents. If there is a
discrepancy between a coverage policy and a self-insured benefit plan, the provisions of the benefit plan will govern. With respect to Medicare
and Medicaid members, this policy will apply unless Medicare or Medicaid policies require different coverage.
Coverage Policy
Use of injectable ketamine to treat symptoms of all mental health (including major depressive disorder, obsessive compulsive disorder, and
post-traumatic stress syndrome) and substance-related disorders is considered INVESTIGATIVE and, therefore, is NOT COVERED for these
indications.
Page 1 of 2
2014 Medica. Medica is a registered service mark of Medica Health Plans. "Medica" refers to the family of health plan businesses that includes Medica Health
Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, and Medica Self-Insured, and Medica Health Management, LLC.
Prior Authorization
Prior authorization is not applicable. Claims for this service are subject to retrospective review and denial of coverage, as investigative services are
not eligible for reimbursement.
Coding Considerations
Use the current applicable CPT/HCPCS code(s).
Ketamine J3490 (miscellaneous, unclassified drugs) with product-specific NDC
Decision Date: 8/7/14
Re-Review Date(s):
Page 2 of 2
2014 Medica. Medica is a registered service mark of Medica Health Plans. "Medica" refers to the family of health plan businesses that includes Medica Health
Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, and Medica Self-Insured, and Medica Health Management, LLC.