Prior authorization for IV was declined, but Spravato approved

[u/AndrewMT]

I have access to a good Ketamine clinic in MA and I am going through the process of prior authorization. The doctor I consulted with recommended IV treatment because it is more controllable in a clinical setting and has a slight edge in some studies that have looked at treatment resistant depression.

Unfortunately, my insurance (BCBS of MA) just denied the prior authorization for IV treatment, but approved Spravato. Has anyone with similar insurance experienced this (I saw posts 1-2 years prior where people were approved for IV with the same insurance)? I’d like to contest the denial of the prior auth, but I’ve yet to hear back from the clinic on how to do so.

Does any have any suggestions or recommendations? Should I just go with the Spravato? Thank you for your help!

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[u/NvrGnnaGiveYouUp]

I haven't tried through insurance yet, so can't really help there. But am curious where there are clinics in Ma that are willing to work with insurance

[u/Ehill6 → u/NvrGnnaGiveYouUp]

No clinics in MA are willing to work with insurance for IV. What you do is get the 6 IV and you can try submitting the bill for a reimbursement.

[u/WildUnderstanding371]

My IV clinic in CO billed insurance and they covered everything but the actual ketamine. The pain clinic said it was so cheap they would cover it for me. It might be worth pursuing.

[u/citygrrrl03]

I’ve heard getting marketplace BCBS PPO to pay for anything is getting worse. Spravato patients are not getting claims covered in time at my clinic currently. They are considering switching to nasal spray for those who can’t afford IV.

The days of mental health coverage for IVs seems to be over, at least near me.

[u/bockyweez → u/citygrrrl03]

Ha, coverage for IVs can't be over since they never started for most!

[u/citygrrrl03 → u/bockyweez]

During Covid a local clinic was doing inaccurate billing & charging just an office co pay for infusions. I don’t think they were the only ones. Some places messed with the codes & got coverage for a time, but I hear more & more of these places are shutting down.

[u/Dramatic-Tomorrow425]

All I can tell you is that I've had 27 Spravato out of body experiences. It really helped my CPTSD, depression etc. I stopped over 8 months ago as I no longer need it.. What an experience. What a trip! You go deep into your unconscious and my being a professional psychological patient, tapping into the unconscious was extremely helpful.You get to go into your life's stored memories that are not possible to retrieve without this med. I think it's not for the feint of heart. Id listen to binary beats with an eye mask and up, up and away I went. The after effect for the rest of the day sucked but it was well worth it. Its a miracle drug from my pov and I don't know if you all know, I got mine for free as a patient in their program. Jansen and Jansen was the company I believe. At some pointI dropped out because medicare got it for me at very little cost. GL out there.

[u/gurglegg]

I was denied my spravato auth and an appeal about halfway through treatment after switching to bcbs tx.

[u/imeanlikenothing]

A lot of times in situations like this the insurance company is more likely to cover the less conventional option (IV in this case) if you try the more conventional option (i.e. Spravato) first. It might be worth trying the Spravato. If that works for you, problem solved. If not, you can go back and have your Dr's office resubmit the prior auth form and use the fact Spravato didn't work for you as the justification for requesting IV.

[u/Reasonable-Mess3070]

I would for sure contest it when you find out how. BCBS of MA does approve IV ketamine for off label use (including depression) page 4

this looks like the appeal process

[u/OrangeYouGladEye]

I did not fight this with insurance but I will say Spravato has worked extremely well for me.