Ketamine infusions involve the intravenous delivery of the drug ketamine, often administered in a specialized outpatient clinic setting. This treatment has gained attention for its fast-acting effects on certain complex conditions. Standard Medicare, specifically Parts A and B, typically does not cover ketamine infusions when they are used for conditions like depression or chronic pain. This denial occurs because the use of ketamine for these indications is considered off-label and does not meet the established criteria for Medicare reimbursement.
What Ketamine Infusions Treat
Ketamine was originally approved by the Food and Drug Administration (FDA) as a dissociative anesthetic for surgical procedures. It is still FDA-approved for this purpose, administered at higher, anesthetic doses. However, its use in an infusion format for mental health and pain conditions is considered “off-label” because this specific use and delivery method are not included on the FDA-approved label.
Ketamine infusions are commonly used for treatment-resistant depression and suicidal ideation when traditional antidepressants have proven ineffective. They are also utilized for certain chronic neuropathic pain syndromes, such as Complex Regional Pain Syndrome (CRPS). In these therapeutic settings, the drug is delivered at much lower, sub-anesthetic doses.
Medicare Policy on Unapproved Treatments
Original Medicare (Parts A and B) requires that covered services and drugs must be deemed “medically necessary.” Crucially, they must also be FDA-approved for the specific indication for which they are prescribed. Ketamine infusions for depression or pain generally fail this test because they are administered for an off-label purpose. The Centers for Medicare & Medicaid Services (CMS) currently considers this use of ketamine to be “investigational” for these conditions.
Medicare Part B covers certain infused drugs provided in an outpatient setting. However, coverage is only granted if the drug is approved for the condition being treated or if the off-label use is supported by specific medical compendia. Since the intravenous administration for mental health or chronic pain is not an approved indication, it does not meet these stringent criteria for coverage.
When Coverage Might Be Possible
While Original Medicare generally denies coverage, a few specific scenarios might allow for financial assistance.
Inpatient Hospitalization
If the ketamine infusion is administered during a medically necessary inpatient hospitalization covered under Medicare Part A, the cost of the drug might be bundled into the overall hospital stay. However, the typical series of maintenance infusions for depression or pain are rarely administered in this inpatient setting.
Clinical Trials
Coverage may also be available if the patient is participating in an approved clinical trial studying the efficacy of ketamine for a covered condition. In this case, Medicare may cover the routine patient care costs that are part of the trial.
Medicare Advantage Plans
Some private Medicare Advantage Plans (Part C) may occasionally offer supplemental benefits that cover treatments not covered by Original Medicare. This coverage is highly variable and requires direct verification with the specific plan.
Costs and Patient Payment Responsibility
When Medicare denies coverage for an outpatient ketamine infusion, the patient is responsible for the entire cost of the treatment. A single intravenous ketamine infusion session typically costs between $400 and $800. Since an initial course often involves six infusions, the total out-of-pocket cost for the induction phase can reach several thousand dollars.
If a provider believes Medicare will deny the claim because the service is not considered medically necessary or is investigational, they must issue an Advance Beneficiary Notice of Noncoverage (ABN). The ABN informs the patient before the service is rendered that Medicare is likely to deny payment, transferring the financial responsibility to the patient. Signing this notice means the patient agrees to pay the full cost if Medicare does not cover the service.