Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for ketamine injections provided and future services for treatment of the enrollees major depressive disorder. Findings:  The 3 physician reviewer found that Ketamine does not have U.S. Food and Drug Administration (FDA) approval for treatment resistant depression and the off label use of it for this purpose is considered investigational. In addition, there are concerns regarding the potential routine use for ketamine in clinical practice. One concern is the duration of anti-depressive effects of ketamine. Studies have shown that patients who respond well to a single dose may relapse within two to three weeks and a majority of those who receive repeated short-term infusions of ketamine may relapse within the month after their last treatment. In this case, the results of the ketamine infusions have not consistently been positive. After several treatments with ketamine, the patient was seen in a follow-up appointment with her primary psychiatrist and noted to have some improvement in mood but was highly anxious after a recent ketamine injection. More recently, during her ketamine infusion appointment, a provider documented that the patient had regressed in treatment and should follow-up in two weeks rather than the previous five-week interval. Her PHQ-9 score was documented as 19.  At a follow-up appointment the next day the patient was documented as being in poor spirits with poor level of functioning. She reported that she discontinued sertraline and reported during the visit that she should take the sertraline regularly. She noted that a recent ketamine infusion left her feeling unsettled.  For the reasons provided, the ketamine injections provided and future services were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.