Treatment-resistant depression: what actually counts, and why it matters for your insurance
Every Spravato and most ketamine coverage policies are gated on 'treatment-resistant depression.' Here is what that phrase formally means, how to document it, and how to talk to your prescriber to avoid an accidental denial.
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TL;DR
- TRD typically means failure of 2+ antidepressants at adequate dose and duration.
- Adequate = at least 6-8 weeks at therapeutic dose for each trial.
- Documentation in your medical record is what the prior-auth reviewer looks at.
- If you have only tried one medication, you are not yet TRD for insurance purposes.
'Treatment-resistant depression' is a clinical term with a specific operational meaning for insurance. If you are considering Spravato or insurance-covered IV ketamine, this is the gate.
The formal definition
The consensus definition across major US payers is: major depressive disorder (MDD) that has not responded adequately to at least two antidepressants from different pharmacologic classes, each at therapeutic dose and for adequate duration (generally 6-8 weeks).
The operative words are 'adequate dose' and 'adequate duration.' A two-week trial of a starting-dose SSRI does not count. Many patients who feel they have 'tried everything' have actually tried many medications for too short a time to qualify under payer criteria.
What the prior-auth reviewer actually sees
They pull your pharmacy claims history and progress notes from your prescriber. If those records show two adequate trials with documented response ('no meaningful response,' 'patient continued to score 15 on PHQ-9 after 8 weeks of sertraline 200mg daily'), approval is usually smooth.
If the notes are sparse - 'tried a few antidepressants, nothing worked' - the prior auth often comes back denied and you have to appeal.
What to ask your prescriber for
Before your Spravato or ketamine consult, ask your prescriber to write a letter of medical necessity that specifically lists each prior medication trial: the drug, the dose, the duration, and the response. Include the exact PHQ-9 or Hamilton scores at the start and end of each trial if available.
What counts as a class
SSRIs (fluoxetine, sertraline, escitalopram, etc.), SNRIs (venlafaxine, duloxetine), atypicals (bupropion, mirtazapine), tricyclics (amitriptyline, nortriptyline), MAOIs (phenelzine, tranylcypromine) are the five major classes. Augmentation with atypical antipsychotics (aripiprazole, quetiapine) often counts as an additional 'trial' for insurance purposes.
Therapy is strongly recommended but is not a 'drug trial' and does not substitute for one in payer eyes.
If you are not yet TRD on paper
You have two options. The first is to work with your prescriber on a plan that gets you to the threshold: adjusting dose, committing to duration, documenting scores carefully. The second is the cash/self-pay path, which has no TRD requirement.
Neither path is wrong. Both are worth discussing with a prescriber who has walked patients through Spravato or ketamine coverage before.