Spravato Prior Authorization Denied? What to Do Next

If you've had a SPRAVATO® (esketamine) prior authorization denied by your insurance plan, start by finding out exactly why. The denial letter names a reason, and that reason usually points to the next step: sending missing records, fixing a paperwork problem, asking for a clinician-to-clinician review, or filing a formal appeal. A denial is a decision about the request as submitted, not a judgment of how serious your depression is. Nobody can promise approval on a second try, but some denials come down to documentation you and your care team can help supply.

What is prior authorization, and why does Spravato need it?

Prior authorization is a review your health plan does before agreeing to cover a treatment, comparing your clinician's request against its own written criteria.

According to its FDA prescribing information, Spravato is approved for adults with treatment-resistant depression (TRD), either on its own or with an oral antidepressant, and for depressive symptoms in adults with major depressive disorder who have acute suicidal thoughts or behavior, together with an oral antidepressant. It is available only through a restricted program called the SPRAVATO REMS: you give yourself the nasal spray under supervision at a certified healthcare setting and are monitored for at least two hours after every dose. You can't drive until the next day after a restful sleep, so plan for someone to drive you home. See our overview of Spravato treatment.

What are the usual Spravato prior authorization requirements?

The plan policies we reviewed, and the manufacturer's prior authorization toolkit for clinicians, share a core list:

• You are 18 or older.
• Records show at least two antidepressants, at an adequate dose and duration, did not help enough.
• A baseline depression rating scale score is on file, such as the PHQ-9, MADRS, HAM-D, QIDS or BDI.
• A psychiatrist prescribes or is involved — that is the plan's own wording. Who prescribes varies by practice, so ask the practice you're working with how it meets your plan's prescriber rules.
• Treatment will happen at a REMS-certified site with at least two hours of monitoring.

According to that toolkit, some plans also ask for documentation that bipolar disorder has been ruled out, a check of the state prescription-monitoring database, a trial of psychotherapy such as CBT, or a blood pressure or cardiovascular assessment.

"Treatment-resistant" has no single definition, and the FDA indication gives no number. England's NICE and a 2021 international expert consensus in the American Journal of Psychiatry describe it as depression that has not responded to at least two different antidepressants in the current episode. Your plan's own wording is what counts. See who may qualify for Spravato.

Why do Spravato prior authorizations get denied?

Each item on that list is a place a request can fall short. Look for these gaps in your letter:

• The antidepressant history is incomplete. Plans want medication names, doses and dates, sometimes with pharmacy fill dates. A medication taken only briefly or at a low starting dose may not count as a full trial, and plans set their own rules, including for one you stopped because of side effects. See how long antidepressants take to work.
• The trials happened in an earlier episode. Definitions often refer to the current episode, so older treatment may be weighed differently.
• No baseline rating scale was submitted.
• The plan requires an oral antidepressant alongside Spravato. The FDA label has allowed Spravato on its own for TRD since January 2025, but plan policies don't all match the label.
• The prescriber doesn't meet the plan's rules. Several plans require a psychiatrist to prescribe or consult — again, the plan's own wording. Ask the practice how its prescribers meet your plan's requirement; if the prescriber types are new to you, here's the difference between a psychiatrist and a psychiatric nurse practitioner.
• There is a coding or clerical problem. Per the manufacturer's coding overview as reviewed (dated December 2025), a new billing code for Spravato, J0013, replaced S0013 on January 1, 2026. If your letter points to a code, a form or a missing signature, ask the practice's billing team to check it; it may be fixable with a corrected request.
• The plan's criteria differ from what you expected. Some plans count medication classes, not individual drugs.
• It was a renewal. Approvals last a set time, and renewals usually need follow-up rating scale scores showing response compared with your baseline.

What do plan criteria actually look like?

Two examples show how plans differ. They are examples only, from policy versions as reviewed in late September 2026; yours may say something else, and policies change.

UnitedHealthcare commercial plans (policy 2026D0069Q, effective May 1, 2026, as reviewed): at least two different antidepressants that didn't work, each at an adequate dose for at least 8 weeks; a baseline rating scale; and a psychiatrist prescribing or involved. For TRD, Spravato may be approved on its own or with an oral antidepressant. Approvals last up to 12 months; renewal needs documented response or remission.

Blue Shield of California commercial plans (policy effective March 1, 2026, as reviewed): age 18 or older; from May 1, 2026, inadequate response to two antidepressants from different classes, or intolerance of or a reason not to take every class; a baseline rating scale; and a psychiatrist prescribing or consulting. The policy text as reviewed still listed a concurrent oral antidepressant as required. The first approval lasts 2 months; renewals last 6 months with documented response or remission.

For any other plan, ask the practice or your insurer for the current written criteria.

Spravato prior authorization denied: what should I do first?

1. Read the denial letter all the way through. Find the reason, the criterion it cites and the appeal instructions. It should also state your appeal deadline. Don't miss it.
2. Call the practice that submitted the request. Share the letter and ask whether something was missing. Sometimes the simplest route is a new, complete request rather than an appeal.
3. Keep a log. For every call, note the date, the person's name and any reference number. Keep copies of what you send.
4. Don't change your medications to fit the criteria. Any change should come from the clinician who prescribes them.

How can I help build my medication history?

If you've changed doctors, moved or used different pharmacies, your records may be scattered. You can help fill the gaps:

• List every antidepressant you can remember: the highest dose, rough start and stop dates, and why it ended (not enough help, or side effects).
• Ask your pharmacy for a printout of your fill history, with names, doses and dates.
• Sign release forms so past prescribers can send their records.
• Note any add-on medications and any therapy you tried, and for how long.

Our guide to organizing your depression medication history walks through it step by step. If a medication stopped helping recently, see when an antidepressant stops working.

What is a peer-to-peer review?

A peer-to-peer review is a phone conversation between your prescribing clinician and a reviewing clinician at the plan, where your clinician can explain your history directly. Not every plan offers one and timing rules vary, so ask the practice soon after the denial. You usually aren't on the call, but you can make sure your clinician has your full medication history.

How does a formal appeal work?

An internal appeal asks your plan to reconsider its decision; the letter should tell you how and by when. Appeals often include a letter of medical necessity from your clinician. A strong letter typically covers:

• your diagnosis and how long this episode has lasted
• each antidepressant tried, with dose, duration, dates and what happened
• your baseline rating scale score
• why Spravato is a reasonable next step for you now
• how you meet each of the plan's criteria, point by point
• confirmation that treatment will happen at a REMS-certified site

Some plans also offer an external review, where an independent reviewer looks at the case after an internal appeal. Ask your plan whether it applies and how.

What if the answer is still no?

Ask your clinician whether you could meet the plan's criteria later, and which other depression treatments make sense meanwhile. A Spravato denial doesn't close the door on care.

Johnson & Johnson offers a patient support program called SPRAVATO withMe; you can find it by name through the manufacturer. Its savings programs are for commercial insurance only and exclude Medicare, Medicaid, TRICARE, the Department of Defense, the VA and other state or federal programs. They help with out-of-pocket costs; they don't change your plan's decision. You can also check which insurance plans we accept, and confirm your plan's details with your insurer.

Waiting on paperwork while you're struggling is hard. If your depression gets worse or you have thoughts of suicide, don't wait on insurance: call or text 988 (Suicide & Crisis Lifeline) or call 911.

For a psychiatric evaluation at MindVibe, start with our booking process — and when you book, ask who would prescribe for you and how your plan's prescriber rules would be met. You'll find our REMS-certified Spravato treatment centers listed on the Spravato treatment page.

Important safety information

Spravato is a Schedule III controlled substance, and it carries a boxed warning. It can cause sedation (sleepiness) and dissociation — a feeling of being disconnected from yourself, your thoughts or your surroundings — as well as respiratory depression (slowed breathing). These risks are why Spravato is given only in healthcare settings certified in the SPRAVATO REMS — and why a healthcare provider monitors you for at least two hours after each dose. Spravato carries a potential for abuse and misuse. And because antidepressants may increase suicidal thoughts and behaviors in people 24 and younger, call your provider right away if depression or suicidal thoughts are new or getting worse. One thing Spravato has not been shown to do: prevent suicide, or reduce suicidal thoughts or actions. Don't drive or operate machinery until the next day — and only after you've had a restful sleep. Spravato is approved for adults only. It shouldn't be used if you have aneurysmal blood-vessel disease, an arteriovenous malformation, a history of bleeding in the brain, or an allergy to esketamine, ketamine or any of its ingredients. Read the full Prescribing Information, including the Boxed Warning, and the Medication Guide.

If you are in crisis: call or text 988 to reach the Suicide & Crisis Lifeline, available 24/7, or call 911 or go to the nearest emergency room if you or someone else is in immediate danger.

Sources

• SPRAVATO Prescribing Information, Johnson & Johnson, rev. March 2026: https://www.jnjlabels.com/package-insert/product-monograph/prescribing-information/SPRAVATO-pi.pdf
• SPRAVATO Medication Guide (DailyMed): https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d81a6a79-a74a-44b7-822c-0dfa3036eaed&audience=consumer
• UnitedHealthcare, Ketalar and Spravato Commercial Medical Benefit Drug Policy 2026D0069Q, eff. May 1, 2026: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/ketalar-spravato.pdf
• Blue Shield of California, esketamine (Spravato) Commercial Policy, eff. March 1, 2026: https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/bsc-med-benefit-drug-policy/esketamine-Spravato-COMM-UMRx-provider.pdf
• J&J, SPRAVATO Prior Authorization Toolkit (Jan. 2025): https://www.spravatohcp.com/files/Prior_Authorization_Toolkit.pdf
• J&J, SPRAVATO Coding Overview (Dec. 2025): https://www.spravatohcp.com/files/spravato_coding_overview_brochure_digital_version.pdf
• J&J, SPRAVATO withMe Savings Program Requirements (Oct. 2025): https://spravato.com/files/spravatowithmeprogramrequirements.pdf
• NICE TA854, esketamine for treatment-resistant depression: https://www.nice.org.uk/guidance/TA854/chapter/1-Recommendations
• McIntyre RS, et al., Am J Psychiatry 2021, expert opinion on ketamine and esketamine in TRD: https://adaa.org/sites/default/files/Banners/APA%20American%20Journal%20International%20Guidelines%20Ketamine%20Esketamine%20Final%202021.pdf

Frequently asked questions

Why was my Spravato prior authorization denied?

Your denial letter states the reason. Typical gaps are an incomplete antidepressant history (missing doses, dates or durations), no baseline depression rating scale, a plan rule requiring an oral antidepressant alongside Spravato, a prescriber who doesn't meet the plan's psychiatrist rule, or a coding problem. Ask the practice which documents could address the stated reason.

Can the practice resubmit instead of filing an appeal?

Sometimes. If the denial came from missing records or a clerical error, the practice may be able to send a new, complete request. If the plan reviewed full records and still said no, a peer-to-peer review or formal appeal may fit better. Ask the practice which path suits your letter, and watch your appeal deadline.

What is a letter of medical necessity for Spravato?

It is a letter from your clinician explaining why Spravato is appropriate for you, often sent with an appeal. It lists your diagnosis, each antidepressant tried with dose, duration and response, your baseline rating scale score, and how you meet each plan criterion. You can help by providing a dated medication history and pharmacy fill records.

Do I have to take an oral antidepressant for insurance to approve Spravato?

It depends on your plan. Since January 2025, the FDA label has allowed Spravato on its own or with an oral antidepressant for treatment-resistant depression in adults. Some plan policies allow either; others still list an oral antidepressant as required. Check your plan's current criteria, and never start or stop a medication on your own.

How long do I have to appeal a Spravato denial?

Deadlines vary by plan and type of coverage, so there is no single answer. Your denial letter should list your appeal deadline and explain how to file. Don't miss it. If the letter is unclear, call the member services number on your insurance card, and note the date, the representative's name and any reference number.

Can the SPRAVATO withMe savings program help if I have Medicare or Medicaid?

No. The manufacturer's savings programs are for people with commercial insurance only. They exclude Medicare, Medicaid, TRICARE, the Department of Defense, the VA and other state or federal programs. They help with out-of-pocket costs and don't change a plan's decision. Ask your insurer about options for your type of coverage.

This article is for educational purposes only and is not medical, legal or insurance advice, a diagnosis, or a treatment recommendation. Coverage rules vary by plan and change over time. Talk with your own clinicians and your insurer before making any change to your care.