Diagnosis: Depression.

Treatment: procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The insurer denied coverage for procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour); ketamine intravenous infusion therapy.

The denial is upheld.

This patient has a history of post-traumatic stress disorder, major depression disorder, and generalized anxiety disorder. The patient has been under the care of the Anesthesiologist received intravenous (IV) ketamine therapy.

Ketamine or Esketamine may be indicated for treatment resistant depression, severe unipolar without psychotic features, if patients have failed other indicated treatments for resistant depression. A patient receiving ketamine or esketamine should be under the care of psychiatrist who can determine whether other treatments have been appropriately administered and can monitor the outcome of the ketamine/esketamine trial.

For patients with unipolar major depression who do not respond to initial treatment with an antidepressant medication, treatment strategies include:

1) Augmentation (adding a treatment)
2) Medication (eg, second-generation antipsychotic, lithium, a second antidepressant, or triiodothyronine)
3) Psychotherapy
4) Electroconvulsive therapy
5) Repetitive transcranial magnetic stimulation
6) Supplementary and supportive interventions such as exercise

7) Switching treatment
8) Different antidepressant
9) Psychotherapy
10) Electroconvulsive therapy
11) Repetitive transcranial magnetic stimulation.

There is information about the patient failing trials or having side effects to Lexapro, Buspirone, Latuda, Lamictal, Wellbutrin and Zoloft. There is no information from treating psychiatrist, psychiatric assessment and information if other recommended pharmacological (augmentation) or non-pharmacological interventions were tried.

A patient receiving ketamine or esketamine should be under the care of psychiatrist who can determine whether other treatments have been appropriately administered and can monitor the outcome of the ketamine/esketamine trial. There is no initial evaluation showing the baseline symptoms and ongoing assessment (rating scales) monitoring progress/outcome.

There is no information supporting that requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The risks are not increase over other standard treatments.

The carrier's denial of procedure code 96365 (intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour (ketamine intravenous infusion therapy) should be upheld.