A recent Psychology Today article noted that three in ten people who are suffering from depression are treatment-resistant. Yet despite this—and even though ketamine has become one of the most effective and frequently-used drugs for treatment-resistant depression and PTSD—insurance coverage for the drug remains “spotty” at best. All too often, ketamine is labeled as “investigative,” which severely limits access for patients who could potentially have their lives significantly improved by the drug.
Ketamine treatment is extremely effective for severely depressed and suicidal patients. If your doctor prescribed ketamine and then your insurer denied the treatment, calling it “experimental” or “investigative,” you may be feeling frustrated, even angry. Should you find yourself in such an untenable situation, attorney Scott Glovsky can help you get the treatment you need for your mental health condition. A ketamine insurance claim denial does not have to be the final word; the Law Offices of Scott Glovsky will fight for your right to receive the treatment your doctor believes is best for you.
Are Ketamine Treatments Approved by the FDA to Treat Mental Health Conditions?
The drug ketamine was approved in 1970 as an anesthetic drug. Ketamine, however, is a “racemic” drug, with both S and R mirror image molecules. S-ketamine is the form of ketamine that is believed to be extremely beneficial in treating drug-resistant depression, PTSD, and anxiety. A nasal spray form of S-ketamine, or esketamine was approved in 2019 for the treatment of depression and other mental issues. This nasal spray is sold under brand names like Spravato, and Ketanest, as well as others. The Yale School of Medicine states, “When administered correctly and under the supervision of a professional, ketamine can be a life-changing treatment for major depression.”
The FDA, when approving racemic ketamine 60 years ago for use as an anesthetic, failed to put restrictions on the drug. So, while intranasal esketamine drugs like Spravato can only be used under very controlled conditions, racemic ketamine—which also contains S-ketamine—has no such restrictions. Of course, it is doubtful that a doctor would prescribe racemic ketamine for depression, simply because the lines are so fuzzy regarding restrictions and regulations.
Further, the IV use of esketamine for mental illnesses has not yet been approved by the FDA. Your doctor likely prescribed intranasal esketamine for your treatment-resistant depression, however, whether or not your insurance company agreed to pay for the drug may be in question. While racemic ketamine has not received the FDA stamp of approval, some insurers are covering ketamine infusions for treatment-resistant depression.
Have Ketamine Treatments Been Proven to Be Safe and Effective?
Ketamine and psychedelics (also being used for treatment-resistant depression) work in very different ways. While ketamine relaxes the brain’s chandelier cells which produces an “expanded state of awareness,” psychedelics overwhelm the chandelier cells rather than relax them. Psychedelics affect the gut (often known as the body’s second brain), potentially causing nausea and vomiting, but ketamine does not affect the gut, making it a less “turbulent” treatment for those with depression, anxiety, and PTSD.
PubMed reported on a longer-term study on nasal ketamine (esketamine) from 2019 that found that 55.3 percent of female adults in the trial achieved stable remission of depression symptoms and that the risk of relapse among this group decreased by 51 percent. It should be noted, however, that in this particular study, esketamine was given along with the patients’ normal oral anti-depressant. One particular benefit of ketamine is that the anti-depressant effects are felt within about 40 minutes, rather than the weeks that oral antidepressants generally require.
Why Might Your Ketamine-Related Treatments Be Denied by Your Insurer?
Despite a significant body of research surrounding ketamine used for resistant depression symptoms, insurance companies continue to maintain that ketamine treatments are experimental or investigational. Because ketamine is an older drug with a patent that has long since expired, it will never be a billion-dollar drug for a pharmaceutical company, so there is little “draw” for big pharma to study and market ketamine for depression. Since ketamine has FDA approval as an anesthesia drug, it can be used off-label for depression, anxiety, and PTSD, however, a lack of research for these uses can result in insurers refusing to pay for ketamine-related treatments.
A ketamine insurance claim denial after your doctor has prescribed the treatment, believing it will help you, can be disheartening. You need a strong advocate like attorney Scott Glovsky who can work on your behalf to get the treatment approved. R-ketamine is being actively studied for resistant depression as it shows greater potency and longer-lasting antidepressant effects than esketamine (Spravato) in many studies. If your doctor prescribes R-ketamine as an anti-depressant, your insurer may claim it is “non-formulary,” which is how drug companies say “Esketamine is good enough, we won’t pay for R-ketamine.”
What Steps Can You Take for a Ketamine Insurance Claim Denial?
As with any insurance claim denial, you do have options following a ketamine insurance claim denial. You have the right to file an internal appeal, which essentially asks your insurer to take another look at the claim. You may submit a letter from your doctor with this internal appeal that details why you will benefit from ketamine-related treatments. If your internal appeal is unsuccessful, you can file an external appeal that asks a neutral third party to look at your claim and reverse the denial. The third party’s decision is binding on the insurance company, so if your external appeal is successful, your ketamine insurance claim denial will be reversed, and the treatment paid for by your insurance company. That said, depending on your specific situation, your best course of action might not be to file an external appeal. The Law Offices of Scott Glovsky can counsel you as we understand how to fight for your rights and your health.
What Insurance Companies Are Known to Deny Ketamine Treatments?
While any insurance company can potentially deny a treatment, including ketamine treatments, a ketamine insurance claim denial in California could come from one of the following insurers:
- Anthem Blue Cross
- Blue Shield
- HealthNet
- Kaiser
- UnitedHealthcare
- Aetna
- and others
How the Law Offices of Scott Glovsky Can Help Following a Ketamine Insurance Claim Denial
Attorney Scott Glovsky has successfully litigated ketamine cases in the past, so if your insurance company has issued a ketamine insurance claim denial, we are ready to help. If you have suffered from depression for a significant amount of time and receive minimal relief from oral antidepressants, ketamine could be your doctor’s choice to help you with resistant depression, PTSD, or anxiety.
Receiving a ketamine insurance claim denial is certainly discouraging, but it is important that you not give up until you have spoken to attorney Scott Glovsky. You don’t need an army of lawyers to fight for you—you just need one person who cares enough about you and your case. At the Law Offices of Scott Glovsky, our victories have impacted millions of insurance policyholders by forcing insurers to change their behavior and approve medically necessary treatments. Contact the Law Offices of Scott Glovsky today.