How to appeal a Spravato (Esketamine) denial
Spravato denials target the buy-and-bill drug cost, the REMS/monitoring administration codes, and step-therapy, the drug is expensive and payers scrutinize the treatment-resistant-depression criteria before covering it.
Common code: HCPCS S0013 (drug) + G2082/G2083 (administration & monitoring)Why it gets denied
- Prior authorization was missing or the treatment-resistant-depression criteria weren't documented
- The administration/monitoring code (G2082 vs G2083) didn't match the dose delivered
- Step-therapy requires oral antidepressant trials that weren't documented
- Drug units on S0013 don't reconcile to the dose
What overturns it
- Document the failed oral antidepressant trials and the concurrent oral antidepressant required by the label
- Obtain prior auth and tie the TRD criteria to the claim
- Select the administration code that matches the dose (G2082 up to 56 mg, G2083 above 56 mg)
- Reconcile drug units to the administered dose
Worth appealing? Spravato is a high-cost buy-and-bill drug the practice pays for up front, so a denial is direct out-of-pocket exposure. These are recoverable when the TRD criteria, prior auth, and dosing are documented.
Common questions
How do I appeal a Spravato (Esketamine) denial?
Spravato denials target the buy-and-bill drug cost, the REMS/monitoring administration codes, and step-therapy, the drug is expensive and payers scrutinize the treatment-resistant-depression criteria before covering it. To overturn it: document the failed oral antidepressant trials and the concurrent oral antidepressant required by the label; obtain prior auth and tie the TRD criteria to the claim; select the administration code that matches the dose (G2082 up to 56 mg, G2083 above 56 mg); reconcile drug units to the administered dose.
Why do Spravato (Esketamine) claims get denied?
Prior authorization was missing or the treatment-resistant-depression criteria weren't documented; The administration/monitoring code (G2082 vs G2083) didn't match the dose delivered; Step-therapy requires oral antidepressant trials that weren't documented; Drug units on S0013 don't reconcile to the dose.
Is a Spravato (Esketamine) denial worth appealing?
Spravato is a high-cost buy-and-bill drug the practice pays for up front, so a denial is direct out-of-pocket exposure. These are recoverable when the TRD criteria, prior auth, and dosing are documented. You pay 25% only on what's recovered, so there's no cost to working the winnable ones.
See how many Spravato (Esketamine) denials you wrote off.
A free assessment shows your real recoverable number. No risk, paid only on what we recover.