Aetna modified CPB 0950 for esketamine (Spravato), effective 2026-02-27. Here's what billing teams need to know before submitting claims.
Aetna, a CVS Health company, updated its esketamine Spravato coverage policy under CPB 0950 Aetna system, covering HCPCS codes J0013, G2082, G2083, and T1503. This change affects psychiatric practices, outpatient infusion centers, and any facility administering esketamine nasal spray to patients with treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation. The stakes are high — Spravato billing runs expensive, and a single documentation gap means a claim denial before you even get to the appeal.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Esketamine (Spravato) — CPB 0950 |
| Policy Code | CPB 0950 |
| Change Type | Modified |
| Effective Date | 2026-02-27 |
| Impact Level | High |
| Specialties Affected | Psychiatry, Behavioral Health, Outpatient Mental Health, Infusion/Administration Centers |
| Key Action | Confirm prior authorization is active, verify two failed antidepressant trials from two different classes, and document augmentation therapy or psychotherapy trials before submitting J0013 claims |
Aetna Esketamine Spravato Coverage Criteria and Medical Necessity Requirements 2026
The Aetna esketamine Spravato coverage policy requires precertification for every claim. No exceptions. Call (866) 752-7021 or fax (888) 267-3277 to get that prior authorization before administration. If you skip this step, you're not looking at a soft denial — you're looking at a hard one.
Medical necessity under CPB 0950 applies to two diagnoses: treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation or behavior. These map to ICD-10 codes F32.0–F32.A for single-episode MDD and F33.0–F33.9 for recurrent MDD, plus R45.851 for suicidal ideation. Every claim needs a confirmed diagnosis documented with a standardized rating scale — the Beck Depression Scale, Hamilton Depression Rating Scale, or Montgomery-Asberg Depression Rating Scale all qualify.
The member must be 18 or older. That's a hard floor. Esketamine billing for a pediatric patient won't pass medical necessity review under this coverage policy.
Treatment-Resistant Depression Criteria
TRD approval requires meeting two separate hurdles — and both must be documented before you submit.
First, the member must show inadequate response to two antidepressants from at least two different classes. The classes matter here. Two SSRIs don't count. The two drugs must come from different mechanisms of action — for example, one SSRI and one SNRI, or one TCA and one MAOI. Each trial must have run at maximally tolerated labeled doses for at least eight weeks, within the past five years.
Second, the member must also show inadequate response to augmentation therapy or evidence-based psychotherapy — cognitive behavioral therapy (CBT), interpersonal therapy (IPT), supportive therapy (ST), or psychoeducational intervention (PEI) — for at least eight weeks during the current depressive episode.
Both requirements must be met. One is not a substitute for the other. Document the start and end dates for each trial in your prior auth request.
MDD with Acute Suicidal Ideation Criteria
For MDD with acute suicidal ideation (R45.851), the criteria shift slightly. The member must still have a confirmed severe MDD diagnosis with standardized rating scale documentation. The suicidal ideation or behavior must be current and active — this isn't a pathway for chronic suicidal ideation that's been stable for months.
Reimbursement under this pathway also requires the same supervision and monitoring requirements. The medication must be administered under direct healthcare provider supervision, and the patient must be monitored for at least two hours post-administration.
Supervision and Administration Requirements
These aren't soft suggestions — they're coverage conditions. If the patient self-administers or goes home before the two-hour monitoring window closes, the claim is at risk. Your documentation for J0013 (esketamine nasal spray, 1 mg) and T1503 (medication administration by a healthcare professional) needs to show both the supervision during administration and the two-hour post-dose monitoring.
Prescribing authority is also restricted. Esketamine must be prescribed by a psychiatrist or in formal consultation with one. A primary care prescriber acting alone does not satisfy this criterion.
Aetna Esketamine Spravato Exclusions and Non-Covered Indications
Aetna has one explicit exclusion under CPB 0950: members with moderate or severe substance or alcohol use disorder who are not currently receiving treatment or medical management are not eligible for esketamine.
This exclusion has real teeth. If your patient has a documented substance use disorder — even in remission — and there's no active treatment or medical management in the record, Aetna will deny the claim. "Not currently receiving treatment" is the operative phrase. If the patient is in a medication-assisted treatment (MAT) program or under active psychiatric management for the substance use disorder, document that clearly and include it in your prior auth submission.
This exclusion also affects your ICD-10 coding strategy. A claim with F32.2 (severe MDD) plus F10.20 (alcohol use disorder, moderate, uncomplicated) with no documented substance use treatment is a denial waiting to happen. Loop in your compliance officer if your patient panel has high comorbid substance use disorder rates — the documentation requirements here are worth a formal internal review before February 27, 2026.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Treatment-resistant depression (TRD) — failed 2 antidepressants from 2 different classes + augmentation/psychotherapy | Covered | J0013, G2082, G2083, T1503, F32.0–F32.A, F33.0–F33.9 | Prior auth required; psychiatrist prescriber required; 2-hr post-dose monitoring required |
| MDD with acute suicidal ideation or behavior | Covered | J0013, G2082, G2083, T1503, F32.0–F32.A, F33.0–F33.9, R45.851 | Prior auth required; active/acute suicidal ideation required; same supervision requirements apply |
| MDD without TRD criteria or suicidal ideation | Not Covered | — | Does not meet medical necessity under CPB 0950 |
| Members with moderate/severe substance use disorder not in treatment | Not Covered | — | Explicit exclusion; document active SUD treatment to avoid denial |
| Pediatric patients (under 18) | Not Covered | — | Hard age floor; no coverage under this policy |
Aetna Esketamine Spravato Billing Guidelines and Action Items 2026
These are the steps your billing team needs to take before the effective date of 2026-02-27 — and at every claim submission going forward.
| # | Action Item |
|---|---|
| 1 | Verify prior authorization is in place before every administration. Call (866) 752-7021 or fax (888) 267-3277. No prior auth means no reimbursement. There is no workaround here. Build this into your scheduling workflow so no patient gets dosed without an active auth on file. |
| 2 | Audit your trial documentation for TRD patients. You need two failed antidepressant trials from two different classes, at maximally tolerated doses, for at least eight weeks each, within the past five years. Pull the pharmacy records, the prescribing notes, and the response assessments. If the documentation lives in a previous provider's chart, get a records release before the auth request. |
| 3 | Document the augmentation therapy or psychotherapy trial separately. This is the second TRD hurdle — eight weeks of augmentation or evidence-based psychotherapy during the current depressive episode. Note the specific therapy type (CBT, IPT, ST, or PEI), the treating provider, and the dates of service. Don't lump this into a general clinical narrative. |
| 4 | Update your charge capture for J0013 and T1503. J0013 (esketamine, nasal spray, 1 mg) is the drug code — confirm your units are correct, since this is a per-milligram code. T1503 covers medication administration by a healthcare professional. Both should appear on claims for each administration session. Cross-reference G2082 and G2083 for the E&M component if an evaluation and management visit occurs during the same encounter. |
| 5 | Document post-administration monitoring in the clinical record. Two hours, minimum. The timestamp should be in the clinical notes, not just implied. This is a coverage condition, not a quality measure — a claim denial on this point is both avoidable and painful. |
| 6 | Screen for substance use disorder before the auth request. If the member has a documented SUD, confirm active treatment or medical management is in place and document it explicitly. Don't let an undocumented SUD torpedo an otherwise clean authorization. |
| 7 | Confirm the prescribing psychiatrist is on the auth. The psychiatrist's NPI needs to be associated with the request. If an internist or NP initiated the referral, the psychiatrist's formal consultation must be in the file. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Esketamine (Spravato) Under CPB 0950
Covered HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| J0013 | HCPCS | Esketamine, nasal spray, 1 mg |
| G2082 | HCPCS | Office or other outpatient visit for the evaluation and management of an established patient (see full descriptor) |
| G2083 | HCPCS | Office or other outpatient visit for the evaluation and management of an established patient (see full descriptor) |
| T1503 | HCPCS | Administration of medication, other than oral and/or injectable, by a health care agency/professional |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| F32.0–F32.A | Major depressive disorder, single episode (range — treatment-resistant depression) |
| F33.0 | Major depressive disorder, recurrent, mild |
| F33.1 | Major depressive disorder, recurrent, moderate |
| F33.2 | Major depressive disorder, recurrent, severe without psychotic features |
| F33.3 | Major depressive disorder, recurrent, severe with psychotic symptoms |
| F33.4 | Major depressive disorder, recurrent, in remission |
| F33.5 | Major depressive disorder, recurrent, in full remission |
| F33.6 | Major depressive disorder, recurrent, unspecified |
| F33.7 | Major depressive disorder, recurrent, in partial remission |
| F33.8 | Other recurrent depressive disorders |
| F33.9 | Major depressive disorder, recurrent, unspecified |
| R45.851 | Suicidal ideations |
A practical note on ICD-10 selection: use the most specific F32 or F33 code that matches the documented severity. "Unspecified" codes (F33.9) are a claims liability when the chart contains a rating scale score that clearly maps to a specific severity level. Use what the documentation supports.
Get the Full Picture
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.