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Spravato (esketamine) prior authorization denied appeal

NMDA antagonist for treatment-resistant depression and MDD with suicidality

To appeal a denied prior authorization for Spravato (esketamine), file a written appeal within 180 days. The appeal must cite the insurer's clinical policy, include a letter of medical necessity from the prescriber, and document each criterion the policy requires. The most common winning evidence is documented prior therapy history and a specialist letter.

Typical PA criteria

  • TRD: MDD with inadequate response to ≥2 oral antidepressants at adequate dose and duration
  • REMS-certified administration site
  • Concurrent oral antidepressant
  • Psychiatrist prescriber

Why your PA was denied

  • Two prior antidepressant trials not documented at adequate dose/duration
  • Non-REMS site
  • Concurrent oral antidepressant not documented
  • Non-psychiatry prescriber

Evidence that overturns the denial

  • ✓PHQ-9 or MADRS baseline
  • ✓Prior antidepressant trials with dose, duration ≥6 weeks, outcomes
  • ✓REMS site certification
  • ✓Psychiatry letter

REMS program restricts administration to certified sites; each session is observed for ≥2 hours. Do not submit for home use.

Draft a Spravato (esketamine) appeal letter

Free analysis identifies the cited policy and missing evidence. Then a finished letter that maps your chart to the criteria.

Draft my appeal letter

FAQ

Why was my Spravato (esketamine) prior authorization denied?+

The most common reasons are: Two prior antidepressant trials not documented at adequate dose/duration; Non-REMS site; Concurrent oral antidepressant not documented. Your denial letter names the specific criteria you did not meet.

How do I appeal a Spravato (esketamine) denial?+

File a written appeal within 180 days that cites the insurer's clinical policy, includes a letter of medical necessity from the prescriber, and documents the criteria the insurer requires.

What evidence overturns a Spravato (esketamine) denial?+

PHQ-9 or MADRS baseline; Prior antidepressant trials with dose, duration ≥6 weeks, outcomes; REMS site certification.

What if the plan excludes Spravato (esketamine) entirely?+

Plan exclusions are different from medical-necessity denials. Check the Summary Plan Description. If the drug is fully excluded, an appeal will not overturn it; you may need a formulary exception or manufacturer assistance program.

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Keep reading

Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.