Esketamine (Spravato) — CPB 0950 | AETNA Coverage Update

Aetna modified CPB 0950 covering esketamine (Spravato) nasal spray, effective February 27, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its clinical policy bulletin CPB 0950 for esketamine (Spravato) nasal spray — a ketamine-derived treatment for treatment-resistant depression (TRD) and major depressive disorder (MDD) with acute suicidal ideation. The update refines medical necessity criteria, prescriber requirements, and continuation approval standards. If your practice bills J0013 for esketamine administration, or submits G2082 and G2083 for associated E&M visits, this coverage policy change affects your precertification workflow starting February 27, 2026.

Quick-Reference Table

Aetna Esketamine Coverage Criteria and Medical Necessity Requirements 2026

Aetna's Spravato coverage policy requires precertification for all participating providers and members on applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate precertification. You can also access the Statement of Medical Necessity (SMN) form through Aetna's specialty pharmacy precertification portal.

To clear medical necessity under CPB 0950, a member must have a confirmed diagnosis of severe major depressive disorder — single or recurrent episode. That diagnosis must be documented using a standardized rating scale. Acceptable tools include the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS), or Montgomery-Åsberg Depression Rating Scale (MADRS). A clinical note without a validated scale score is not enough.

The member must be 18 or older. Esketamine must be administered under direct healthcare provider supervision, and the patient must be monitored for at least two hours post-administration. These aren't soft suggestions — they're hard criteria. If your facility can't document both, the claim will not clear medical necessity review.

From there, the patient must qualify under one of two clinical tracks: treatment-resistant depression (TRD) or MDD with acute suicidal ideation or behavior.

TRD Track: What "Treatment-Resistant" Actually Means to Aetna

For TRD, the bar is specific. The member must show inadequate response to two antidepressants from at least two different classes, with different mechanisms of action. Each must have been tried at the maximally tolerated labeled dose for at least eight weeks. Both trials must fall within the past five years.

Aetna defines the covered antidepressant classes broadly. SSRIs (sertraline, fluoxetine, escitalopram), SNRIs (venlafaxine, duloxetine, desvenlafaxine), TCAs (amitriptyline, nortriptyline), MAOIs, bupropion (aminoketone), mirtazapine/trazodone (NASSAs), and serotonin modulators like vortioxetine and vilazodone all count. Two trials from the same class won't satisfy this — different classes with different mechanisms is the standard.

Beyond two failed antidepressants, the member must also have tried augmentation therapy for at least eight weeks within the past five years, or completed an evidence-based psychotherapy course (CBT, IPT, supportive therapy, or psychoeducational intervention) during the current depressive episode. Both criteria must be met for TRD approval. One without the other won't get through.

MDD with Acute Suicidal Ideation Track

For MDD with active suicidal ideation or behavior, the prior authorization requirements differ. Esketamine must be used alongside an oral antidepressant. The member must have a confirmed MDD diagnosis with acute suicidal ideation or behavior, and esketamine is covered only as a bridge treatment — not ongoing maintenance under this indication.

ICD-10 code R45.851 (suicidal ideations) becomes critical here. Make sure your diagnosis coding reflects the acute nature of the presentation. Don't submit F33.x alone without R45.851 when billing under the suicidal ideation track.

Aetna Esketamine Exclusions and Non-Covered Indications

Aetna has a hard exclusion that your billing team must document against. Members with moderate or severe substance or alcohol use disorder who are not currently receiving treatment or medical management are ineligible for esketamine. Full stop.

This isn't a gray zone. If the patient has a documented substance use disorder (SUD) and is not actively enrolled in treatment or receiving medical management, Aetna will deny the claim. The prescriber must document that active treatment or management is in place if the patient has any concurrent SUD diagnosis. Make sure this is explicit in the clinical notes before you submit.

Aetna also requires that esketamine be prescribed by a psychiatrist — or at minimum, in consultation with one. A primary care physician or internist prescribing independently without psychiatric involvement does not meet CPB 0950 criteria. If your practice relies on collaborative care models, get the psychiatric consultation note in the record before the precertification request goes in.

Coverage Indications at a Glance

Aetna Esketamine Billing Guidelines and Action Items 2026

Spravato billing is operationally complex. It's not a drug you dispense and send home — it requires supervised administration, a two-hour observation window, and E&M documentation for the visit. Every one of those touchpoints is a potential denial if the documentation isn't tight.

If your practice has a high volume of behavioral health patients and you're unsure how the SUD exclusion or psychiatrist requirement interacts with your current workflow, talk to your compliance officer before the effective date of February 27, 2026.

CPT, HCPCS, and ICD-10 Codes for Esketamine (Spravato) Under CPB 0950

Covered HCPCS Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes