Few things are more frustrating than finding a treatment that fits your diagnosis and then waiting on paperwork. For many people considering Spravato® (esketamine), prior authorization is the step that determines how quickly treatment can begin.
The good news is that prior authorization is largely a documentation process. Insurers are checking three things: that your diagnosis matches an FDA-approved use, that your treatment history meets their criteria, and that treatment will be given in a safe, certified setting. This guide walks through each of those, lists what to gather, and explains what to do if your request is denied.
Please note: This article is educational and is not medical or legal advice. Insurance rules vary by plan and by state. The examples below show how requirements commonly look, not what your specific plan will require.
What Is Prior Authorization for Spravato?
Prior authorization (also called precertification) is a review your insurer completes before it agrees to cover a treatment. For Spravato, your clinic typically submits clinical records on your behalf, and the insurer’s reviewers decide whether the treatment meets their medical-necessity criteria.
Some plans handle Spravato under the medical benefit and others under the pharmacy benefit, so it is worth confirming which applies to you early in the process.
What the FDA-Approved Uses Mean for Your Request
Spravato is FDA-approved for two uses in adults: treatment-resistant depression (TRD), either on its own or alongside an oral antidepressant, and depressive symptoms in adults with major depressive disorder (MDD) who have acute suicidal ideation or behavior, alongside an oral antidepressant (Janssen Pharmaceuticals, Inc., 2025). It is not approved for people under 18, and insurers generally limit coverage to these on-label uses.
In the clinical trials that supported approval for TRD, participants had not responded adequately to at least two different antidepressants of adequate dose and duration during the current depressive episode (Janssen Pharmaceuticals, Inc., 2025). That definition is the foundation of most insurance criteria. For more detail, see our guide to what counts as treatment-resistant depression.
Safety screening also plays a role. Spravato is contraindicated for people with aneurysmal vascular disease, arteriovenous malformation, a history of intracerebral hemorrhage, or hypersensitivity to esketamine or ketamine. Because it can temporarily raise blood pressure, clinicians also review cardiovascular and cerebrovascular history before treatment begins (Janssen Pharmaceuticals, Inc., 2025).
What Insurers Typically Require: A Real-World Example
Every insurer publishes its own criteria, and they differ. To make this concrete, here is what Aetna’s published Spravato policy (updated April 2025) requires for TRD (Aetna, 2025).
Diagnosis. A diagnosis of severe major depressive disorder documented with a standardized rating scale, such as the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), or Montgomery-Åsberg Depression Rating Scale (MADRS)
- Age 18 or older
- An inadequate response, during the current depressive episode, to two antidepressants from at least two different classes, each at the maximally tolerated labeled dose for at least 8 weeks within the past 5 years
- An inadequate response to an adequate trial of augmentation therapy (at least 8 weeks) or to evidence-based psychotherapy, such as cognitive behavioral therapy or interpersonal therapy
Administration under the direct supervision of a healthcare provider, with at least 2 hours of monitoring afterward
A prescription from, or in consultation with, a psychiatrist
No moderate or severe substance or alcohol use disorder that is currently untreated
Under the same policy, initial approval for TRD is granted for 3 months, and a 6-month continuation requires documented improvement on a rating scale (Aetna, 2025). Other plans may ask for more or less. Request your own plan’s policy by name (search for “Spravato” or “esketamine”) and compare it against your history.
Two details often surprise patients. Some plans specify the prescriber’s specialty, as the example above does, so ask your plan how it handles prescriber requirements before a request is submitted. And because Spravato may only be given in a REMS-certified setting, confirm that your clinic is certified and in your network (SPRAVATO REMS, n.d.).
Documents to Gather Before You Submit
Strong requests are specific. These items answer the questions reviewers most often need answered:
- Diagnosis and episode details: your MDD diagnosis, its severity, and when the current episode began
- Baseline rating scale scores: dated scores on the scale your plan names (for example, BDI, HDRS, or MADRS)
- A medication history table: each antidepressant’s name and class, highest dose, start and stop dates, and the outcome or reason for stopping
- Augmentation and therapy history: any added medications (such as a second antidepressant, lithium, thyroid hormone, or a second-generation antipsychotic) and any structured psychotherapy, with dates
- Safety information: blood pressure readings, cardiovascular or neurological history, and substance use history
- The treatment plan: the proposed dosing schedule, consistent with FDA labeling, and confirmation that the site is REMS-certified
- A letter of medical necessity: a letter from your prescriber that ties the history together and explains why Spravato is appropriate
Pharmacy fill histories and records from previous prescribers can help confirm dates and doses, especially if you have changed providers or insurers. Request them early, since gathering records is often the slowest part of the process.
Step-by-Step: From Evaluation to Approval
- Complete a clinical evaluation. Your prescriber confirms the diagnosis, scores severity, reviews your treatment history, and screens for safety concerns such as blood pressure.
- Verify your benefits. Call the number on your insurance card and ask whether Spravato requires prior authorization, whether it falls under the medical or pharmacy benefit, whether there are prescriber or site requirements, and what you will owe (deductible, coinsurance, or copay).
- Assemble your records. Use the checklist above so the request is complete the first time.
- Submit the request. Your clinic sends the documentation to the insurer. Ask for a confirmation or reference number.
- Watch for the decision. If a private health plan denies a prior authorization request, it must notify you in writing and explain why, generally within 15 days, or within 72 hours in urgent cases (U.S. Centers for Medicare & Medicaid Services, n.d.).
- Confirm the approval details. Note the approved dates, the length of the authorization period, and where the treatment will be billed.
- Plan for renewal. Approvals are time-limited (3 months initially in Aetna’s example), so bring updated rating scale scores to each renewal to document progress (Aetna, 2025).
At Therapeutic Infusions, our team helps patients through insurance authorization, and we offer immediate appointments so your evaluation does not wait behind the typical three- to six-month psychiatric wait.
Why Prior Authorizations Get Denied, and How to Respond
A denial is usually about documentation or criteria, not about whether your depression is “serious enough.” When a request is denied, the reason in the letter points to what needs fixing. Policies like Aetna’s make the following points decisive (Aetna, 2025):
| Common reason | What can help |
|---|---|
| Treatment history is incomplete or scattered across providers | Request pharmacy fill history and prior records, then build one medication table with doses and dates |
| Past trials did not meet the plan’s dose or duration thresholds | Ask your prescriber to document the highest tolerated dose, any side effects that limited dosing, and exact durations |
| No standardized rating scale on file | Complete the scale your plan names and include dated scores |
| No augmentation or psychotherapy trial documented | Document any added medications or structured therapy, and ask whether the plan accepts either |
| Prescriber or site requirements not met | Ask what the plan requires and confirm your clinic’s REMS certification and network status |
| Untreated substance use disorder or an unresolved medical safety concern | Address and document treatment or management; your clinician can resubmit once the concern is resolved |
For more on this topic, read Why Some Patients Are Denied Spravato and What to Do Next.
What to Do If Your Prior Authorization Is Denied
A denial is not the end of the road. These steps follow the federal baseline for private health plans (U.S. Centers for Medicare & Medicaid Services, n.d.):
- Read the denial letter closely. It should explain why the request was denied and how to appeal. Note every deadline.
- Correct the record. If a document, date, or score was missing, your clinic can send it. Ask the plan whether to resubmit or to file an appeal.
- Ask about a peer-to-peer review. Ask whether your prescriber can speak directly with the plan’s medical reviewer.
- File an internal appeal. You generally have 180 days (6 months) from the denial notice. Include the denial letter, a letter from your doctor, and supporting records. For a service you have not yet received, the plan must complete the appeal within 30 days. Your doctor can file on your behalf if you provide your written request.
- Ask for an expedited appeal if waiting would seriously jeopardize your health. A decision must come as quickly as your condition requires and within 4 business days. In urgent situations, you may request an external review at the same time.
- Request an external review. If the plan upholds its denial, an independent reviewer can examine the decision. In Delaware, the Independent Healthcare Appeals Program covers denials based on medical necessity, as well as experimental or investigational determinations, for covered services. The request must be filed within four months of the insurer’s final decision, and it goes through your insurer, which forwards it to the Delaware Department of Insurance. If the independent reviewer decides in your favor, the insurer is expected to pay for the service (Delaware Department of Insurance, n.d.). The department’s Consumer Services Division can be reached at 800-282-8611 or 302-674-7310.
- Keep a paper trail. Save copies of denial letters, explanation-of-benefits forms, appeals, and doctor letters, and keep notes of every call, including the date, time, and the name and title of the person you spoke with.
These timelines describe private health plans. Medicare, Medicaid, and self-funded employer plans can follow different appeal and external review rules, and your denial letter will identify the process that applies to you. If you live outside Delaware, including in Pennsylvania, contact your own state insurance department for local procedures.
Frequently Asked Questions
Does every insurance plan require prior authorization for Spravato?
Many do, but policies vary by insurer and plan. The only reliable answer comes from your own plan, so confirm it before treatment is scheduled.
Does a denial mean I don’t qualify for Spravato?
Not necessarily. Denials often reflect missing documentation, timing, or administrative criteria, and many can be corrected or appealed. A clinical evaluation can help clarify whether Spravato or another option fits your situation.
What if I haven’t tried two antidepressants yet?
The FDA-approved TRD indication is built around an inadequate response to at least two antidepressants (Janssen Pharmaceuticals, Inc., 2025), so insurers usually expect that history for TRD. Your prescriber can discuss other evidence-based options, such as ketamine infusion therapy, medication adjustments, or psychotherapy, while that history is established.
Get Help Navigating Spravato Approval at Therapeutic Infusions
Therapeutic Infusions is a REMS-certified Spravato® center. Patients receive treatment in private rooms with continuous medical supervision, and appointments are available seven days a week, up to 10 PM. We serve patients from our Wilmington, Delaware headquarters and our Warrington, Pennsylvania campus, and we offer immediate appointments that bypass standard three- to six-month psychiatric wait times.
Learn more about Spravato treatment, review our insurance information, or contact our team to get started.
Find Relief
When Traditional Therapies Fail
Talk with us today to book an appointment.
We specialize in fast-acting treatments for complex mental health conditions. Contact us today to verify your insurance benefits.
If you are in crisis or having thoughts of suicide, call or text 988 (the Suicide & Crisis Lifeline), or call 911 in an emergency.
References
Aetna. (2025, April 16). Spravato SGM 2889-A P2024a_R [Specialty pharmacy clinical policy bulletin]. https://www.aetna.com/products/rxnonmedicare/data/2025/Spravato_SGM_2889-A_P2024a_R.html
Delaware Department of Insurance. (n.d.). Independent Healthcare Appeals Program (IHCAP): Frequently asked questions. https://insurance.delaware.gov/wp-content/uploads/sites/15/2018/04/IHCAP_FAQs.pdf
Janssen Pharmaceuticals, Inc. (2025). Spravato (esketamine) nasal spray, CIII: Full prescribing information and Medication Guide (Reference ID 5580441). U.S. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/211243s019lbl.pdf
SPRAVATO REMS. (n.d.). What is the SPRAVATO® REMS (Risk Evaluation and Mitigation Strategy)? https://www.spravatorems.com/
U.S. Centers for Medicare & Medicaid Services. (n.d.). Internal appeals. HealthCare.gov. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
Leave a Reply