Medical Necessity Determination for Spravato Continuation in Treatment-Resistant Depression

Documentation and Treatment Considerations

The VA/DoD guidelines define treatment-resistant depression (TRD) as failure of at least 2 adequate trials of antidepressants, which the patient appears to meet, but the documentation should explicitly confirm adequate dose and duration for each failed trial 1, 2, 3
The 2022 VA/DoD guidelines suggest ketamine or esketamine as a treatment option in patients who have not responded to several adequate pharmacologic trials, which this patient appears to meet 1, 2, 3
Meta-analyses demonstrate that esketamine as augmentation to ongoing oral antidepressant use improved depressive symptoms and remission rates in patients with TRD at up to 28 days of follow-up 1, 2, 3
The VA/DoD guidelines note that ketamine lacks long-term efficacy and safety trials in MDD, and the bulk of the evidence on short-term efficacy is from studies in patients who have previously not responded to adequate trials of antidepressants 1, 2, 3
Although there is evidence to support longer-term maintenance use of esketamine, it has been primarily studied in patients who have previously not responded to trials of antidepressants 1, 2, 3
Objective evidence of therapeutic benefit is required, with documented improvement in standardized depression rating scales (PHQ-9, MADRS, HAM-D) from baseline to current visit 4, 5

The American College of Physicians and other guideline societies recommend using validated depression scales, such as PHQ-9 or MADRS, to assess therapeutic benefit 4, 5
The VA/DoD guidelines emphasize that esketamine is not recommended as initial treatment but is reserved for patients for whom previous therapies have failed or who have not tolerated previous therapies 1, 2, 3

The American College of Physicians, as reflected in the Annals of Internal Medicine, suggests that a reduction in PHQ-9 score of at least 50% is a threshold for treatment response, which this patient exceeded with an 81% reduction 6

The VA/DoD guidelines support the use of esketamine as a treatment option for patients with treatment-resistant depression who have failed at least 2 adequate antidepressant trials, although the specific guideline reference is not provided in the article, the principle is consistent with maintenance therapy 6