Navigating Payer Policies for Alternative Therapies in TRD

Steven Levine, MD: Dr Rosenzweig, you mentioned this earlier. Sometimes, and often with intranasal esketamine [Spravato], some payers may require prior authorizations prior to approving administration of that therapy. Carrie, can you talk a bit about how payers’ differing prior authorization requirements can impact patient access?

Carrie Jardine: Absolutely. One of the biggest hurdles that we’ve seen recently is that there tends to sometimes be “new year, new insurance.” You’ll have patients who are starting therapy in 2021 and changing payers at the beginning of 2022. If we’re able to catch those, if the patients let us know ahead of time that they’re changing insurance, we can start that prior authorization process before the insurance changes. However, if patients don’t let us know, then we’re sometimes stuck having to find alternative forms of therapy while we’re undergoing that prior authorization process because you’re basically starting the whole thing over with a new payer.

The qualifications can also be different payer to payer in regard to failed therapies. You may have a patient who qualified under X carrier that they had in 2021 and unfortunately no longer qualify for Y carrier in 2022. Being able to start that process and discuss with peer-to-peer review, “This patient has been undergoing this treatment. We’ve been doing measures. Here’s what we’re finding,” can hopefully get over that, but it can be a lengthy process that can delay continued treatment for the patient and be aggravating for the patient and provider.

Steven Levine, MD: It potentially interrupts treatment.

Carrie Jardine: Absolutely.

Steven Levine, MD: That’s important. You were talking about the various scenarios of coding earlier, depending on your contract, the payer, the use of G-codes, comprehensive codes vs S- or J-codes vs CBT [cognitive behavioral therapy] coding for evaluation, management services, prolonged services, and observation and so forth, and all the complexity therein. Certainly, under some payer policies, those prolonged service codes are used to support the administration of intranasal esketamine. But sometimes there may be a limit on the number of those codes you can use or the length of time that those codes will cover. Sometimes the time of service may exceed the cap on that. Can you talk a bit about that?

Carrie Jardine: Yes. We have been utilizing a newer code that was first used in 2021, which is 99417, to bill that additional observation time. That code is what’s called an add-on code. It’s added on to the evaluation and management services that are done. That code is in increments of every additional 15 minutes. CMS [Centers for Medicare & Medicaid Services] does have an edit that will limit that code to 4, which is 60 minutes.

Of course, every patient is different, and not every patient only needs 2 hours or a little more than that. Some patients are there because they’re having nausea or other issues for a longer period of time. We’re seeing that there are payers who are following those CMS guidelines in regard to putting a cap at 4 units. Some of them are paying 4 units and denying the additional. I have seen payers who deny every single unit that you bill if you bill more than 4 units, so you’re having to then go back and submit appeals or a corrected billing, which delays the reimbursement process even longer.

Steven Levine, MD: As you mentioned, each patient is different. Some people need additional support beyond the time that those 4 units of that code cover. How do you ensure that additional patient support from the provider is reimbursed in that scenario?

Carrie Jardine: You can submit an appeal to the insurance company letting them know that the patient was having issues and required additional use of the provider’s time. Documentation is key in those cases. You have to be very clear in your documentation about why you were spending additional time with that patient. “If it’s not documented, it didn’t happen,” is what we follow here as billers. You need to make sure that additional time is documented so that you can file an appeal with the insurance carrier.

Transcript Edited for Clarity