Ketamine for the Treatment of Depression and Other Selected Indications — CPB 0938 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0938 on January 5, 2026, classifying ketamine treatment across all routes of administration as experimental and unproven for depression, PTSD, chronic pain, suicidal ideation, and 11 other indications. If your practice bills CPT 96365–96368 or 96372 for ketamine infusions or injections under Aetna plans, expect denial.

Aetna's ketamine coverage policy under CPB 0938 draws a hard line: no ketamine indication on this list gets covered. Not depression, not PTSD, not suicidal ideation, not chronic pain. Every route—intravenous, intramuscular, intranasal, oral, subcutaneous—falls under the experimental designation. This is one of the broadest categorical denials you'll see from a major commercial payer, and your billing team needs to know exactly which codes are at risk before submitting another claim.

Quick-Reference Table

Aetna Ketamine Coverage Policy and Medical Necessity Requirements 2026

The core of Aetna's ketamine coverage policy is straightforward, and not in a good way for providers. Aetna finds no medical necessity basis for ketamine across 15 separate indications. The policy language is explicit: clinical value and effectiveness have not been established for any of them.

There is no tier of coverage here — no "covered with prior authorization" carve-out, no step therapy pathway that unlocks approval. Prior authorization won't save these claims because authorization assumes there's a covered benefit underneath. There isn't one.

This matters most to psychiatric and pain management practices that have built ketamine infusion programs around depression or suicidal ideation. Those practices are billing CPT 96365 (IV infusion, initial) and 96366 (each additional hour) regularly. Under CPB 0938, those claims have no reimbursement path with Aetna.

The policy also explicitly calls out ketamine-assisted therapy as experimental for depression — a separate designation that closes the door on programs that combine ketamine with psychotherapy protocols. If you've been exploring that billing model for Aetna patients, stop. The policy does not support it.

Aetna Ketamine Exclusions and Non-Covered Indications

Aetna classifies ketamine as experimental, investigational, or unproven for every indication in this policy. There are no covered indications in CPB 0938.

The full list spans psychiatric, pain, and substance use diagnoses:

That last one — ketamine as a diagnostic test for catatonia — is worth noting. Even diagnostic use is excluded. If you were billing for any catatonia-related ketamine administration under F06.1 or F20.2, the policy covers that too.

The breadth of this list is unusual. Most payer policies on ketamine cover at least one pain indication or carve out esketamine (Spravato). Aetna handles esketamine separately under CPB 0950 — so don't confuse the two. CPB 0938 governs racemic ketamine only.

Coverage Indications at a Glance

Aetna Ketamine Billing Guidelines and Action Items 2026

The effective date is January 5, 2026. If you haven't acted on this yet, act now.

CPT, HCPCS, and ICD-10 Codes for Ketamine Under CPB 0938

CPT Codes Referenced in CPB 0938

All five CPT codes below fall under the "other CPT codes related to the CPB" group — meaning they're referenced for context, not as covered codes. Aetna does not cover these services for the indications listed in CPB 0938. Descriptions below match the policy source document exactly.

Key ICD-10-CM Diagnosis Codes Referenced in CPB 0938

These are the diagnosis codes Aetna maps to CPB 0938. A claim pairing any of these codes with CPT 96365–96368 or 96372 for ketamine will trigger the experimental/investigational denial logic.