Ketamine or esketamine treatment decision

Review the claim and determine if the worker may be eligible for ketamine/esketamine treatment as outlined in the key information section. If the worker is not eligible for consideration of ketamine treatment, continue to step 6 to communicate the decision. 

Note: If ketamine/esketamine was approved without meeting the applicable requirements (e.g., application form, medical consultant opinion, psychiatric expedited specialist consultation, etc.), the treatment provider must submit a ketamine - esketamine medication report for review. Once the report is received, continue to step 2.

If the worker may be eligible for ketamine/esketamine treatment IV ketamine, esketamine, review the applicationApplication for trial of ketamine (C1520) is required for consideration of IV ketamine, esketamine, or treatment resistant depression. from the treating specialistA specialist physician, such as a neurologist, psychiatrist, physiatrist, or anesthesiologist who is treating the worker for the condition that ketamine is requested for.(s). Confirm the required documentation is completed and received. 

Reach out to a medical or clinical consultant if you need clarification on the request (e.g., whether the request came from a treating specialist, what diagnosis is being treated, or if the documentation is appropriate, etc.).

If any information is missing or incomplete, contact the worker and treating specialist to discuss the requirements to consider ketamine/esketamine treatment. Explain that an application form outlining the proposed treatment plan is required from the treating specialist.  Explore other standard treatment options that are commonly used and widely accepted that the worker has not tried, as appropriate.  If all standard treatment options have been exhausted, send the Request for Ketamine Treatment Information letter educating them on the requirements for ketamine/esketamine to be considered.

Once all the required documentation is received, continue to the next step.

If the request was received from anyone other than a treating specialist (i.e., psychiatrist, neurologist, physiatrist or anesthesiologist) contact the requestor and send the Request for Ketamine Treatment Information letter outlining the requirements for consideration of ketamine/esketamine treatment. If the request follows a psychiatric independent medical exam, send the letter to the general practitioner instead. 

Prior to making the initial referral to the internal medical consultant, ensure: 

• the injuries and/or conditions accepted and not accepted on the claim are up to date.
• the application form is fully completed.

For subsequent medical consultant referrals (i.e., prior approvals, further actions completed, extension requests, treatment concerns, discharge recommendations, etc.) reference the applicable medical reporting and reason for the referral. 

Once all the information is available for review, make the referral to the internal medical consultant. 

The medical consultant reviews the request for the ketamine/esketamine treatment and provides a medical opinion on whether there is current evidence to support ketamine/esketamine treatment. In some cases, the consultant may recommend alternative treatments or a Psychiatric Expedited Specialist Consultation. If a Psychiatric Expedited Specialist Consultation is recommended, the specialist will evaluate any contraindications during the assessment. 

Review the medical consultant's opinion. Reach out to the medical consultant when clarification of their opinion is required. When the medical opinion: 

• recommends further action, (i.e., clarify entitlement, alternative treatment options, independent medical exam (IME), etc.) contact the worker to discuss the recommendations and the next steps. If applicable, send the appropriate referral. Once the recommended action is completed and the reporting is received, return to step 2.
• recommends a Psychiatric Expedited Specialist Consultation, contact the worker and treating specialist to discuss the recommendation. Send the appropriate referral. Include in the referral, a request for a proposed treatment plan if the treating specialist did not provide one (i.e., the worker was referred to a ketamine clinic). Continue to the next step.
• does not support the proposed treatment, continue to step 6 to communicate the decision. 

Review the Psychiatric Expedited Specialist Consultation (ESC) report 

When the specialist’s report: 

• does not support the proposed treatment, continue to step 6 to communicate the decision.
• supports the proposed treatment as recommended, or with modifications or additional assessments If the compensable condition is a non-psychiatric condition, an additional assessment may be required. This would be outlined in the ESC report., send a referral to the medical consultant who recommended the psychiatric expedited specialist consultation. The medical consultant may contact the specialist to discuss the treatment plan to ensure it remains medically reasonable. 

Review the medical consultant's opinion

When the medical opinion:

• supports the treatment plan, continue to the next step.
• does not support the treatment plan, continue to step 6 to communicate the decision.  

Send a recommendation to the supervisor to confirm the proposed treatment is appropriate. Include the following information: 

• The injuries and/or conditions accepted and not accepted on the claim.
• A brief summary of the proposed treatment and a reference to any information on file submitted by the treating specialist and/or psychiatric expedited specialist consultation.
• Reference to the medical consultant's opinion on file.
• How the proposed treatment meets all the criteria outlined in Policy 04-06, Part II, Application 1.

The supervisor documents their decision to approve or not approve the recommendations and forwards it to the next approver level, if required. Refer to the Levels of Authority manual.

Review the response

Review the supervisor's (and manager, if applicable) recommendation to approve or not approve ketamine/esketamine treatment. 

If additional information is needed, action the supervisor’s (and manager, if applicable) recommendations and resubmit the recommendation.

Review the supervisor's response to approve or not approve the ketamine/esketamine treatment. Action any recommendations, as appropriate. 

Contact the worker to discuss the decision and explain the information used to support the decision. 

If approved: 

• Advise the worker that treatment is arranged and administered through a contracted provider whenever possible. Explain the provider will contact them to arrange the initial intake assessment.
• Discuss the length of the initial trial approval and the expectations during treatment.
• Communicate the decision in writing to the worker and send a copy to the treating specialist. Include the specific details about the proposed treatment or services authorized and when the treatment will be reviewed.
• Continue to the next step to make the referral.
• If the worker is engaged in WCB-supported counselling, send a referral to a psychological consultant to comment on the counselling treatment plan. This should not delay the approval process of the ketamine/esketamine treatment plan. 

If not approved, or the worker is not eligible for ketamine/esketamine treatment: 

• Discuss any alternative standard medical treatment, if recommended by the medical consultant. 
• Communicate the decision in writing to the worker and send a copy to the requestor or treating specialist. 

If a subsequentA subsequent request may include, changes in the treatment plan, extension requests, prior approvals, concerns with the worker's progress, discharge requests. request was reviewed and the worker:

• meets the criteria for an extension or change in treatment plan, explain that authorization will be provided based on the medical consultant's recommendations with reviews every three months, or earlier, to ensure the worker continues to meet the criteria for approval. Document the discussion and communicate the decision in writing. Continue to Step 8. 
• does not meet the criteria for ongoing treatment or has been discharged. Explain why they no longer meet all of the criteria. Document the discussion and communicate the decision in writing.
  • Discontinue ketamine/esketamine treatment and do not continue further with this procedure.
  • Continue to manage the claim and consider alternative treatment options.

Complete the referral form with the reason for the referral, proposed treatment plan, and any concerns noted in the psychiatric ESC report or the medical consultant's review. 

Once the contracted provider (administering clinic) has been confirmed by the Psychology Assistant (PA), the administering clinic arranges the initial intake assessment with the worker. 

Following the intake assessment, the administering clinic arranges a case conference with the claim owner to review the assessment findings and confirm whether treatment can proceed.

If clinical concerns are identified during the intake assessment or at any point during treatment, the administering clinic arranges a case conference with the claim owner to discuss the concerns and determine the appropriate next steps. Document any concerns and consult the medical consultant who reviewed the initial request, as appropriate (e.g., discontinuing treatment, considering alternative options, etc.).

Note: Any requests to attend a non-contracted or out of province provider require advanced approval from the Health Care Consultant and are discussed with the Supervisor.

During the approval period Typically an initial trial period for other conditions may be approved of up to 3 months. Treatment resistant depression may be approved as in initial trial of six (6) administrations of IV ketamine or four (4) weeks of induction SPRAVATO® as an adjunctive therapy. Refer to the proposed treatment plan provided by the specialist.

Call the worker monthly, or as needed, based on the claim circumstances, to discuss their treatment and progress. Talk to them about how the treatment is going. Communicate the treatment plan in writing. 

If applicable, review the psychological consultant’s memo and determine how it impacts the claim and if further action is recommended (i.e., change in treatment approach or alternate counselling provider). If appropriate, contact the worker to discuss the consultant’s recommendations and the next steps, if any. Reach out to the psychological consultant when clarification of their opinion is required. 

Ensure the treatment is in line with the approved treatment plan related to injury(ies). Reach out to a medical consultant if there are concerns with the treatment plan and progress.  

Monitor for updated medical reporting from the contracted provider and the treating specialist. The treating specialistA specialist physician, such as a neurologist, psychiatrist, physiatrist, or anesthesiologist who is treating the worker for the condition that ketamine is requested for.(s) must provide an updated medication reportKetamine - Esketamine Medication Report (C1521) at minimum every three months, or whenever there are concerns with the treatment plan to ensure the worker continues to meet the criteria for approval. 

Note: If ketamine/esketamine was approved without meeting the applicable requirements (e.g., application form, medical consultant opinion, psychiatric expedited specialist consultation, etc.), a medication report should be completed and submitted for review. Once received, return to step 2 and complete steps 2 through 6.

If an extension of treatment was approved, continue to monitor the claim during the approval period as outlined above. 

At the end of the approval period 

Call the worker and gather their opinion on the treatment results and how they felt about the treatment. 

Review all medical reporting from the contracted provider and the treating specialistA specialist physician, such as a neurologist, psychiatrist, physiatrist, or anesthesiologist who is treating the worker for the condition that ketamine is requested for.(s) and consider the effectiveness of the treatment and any benefits, the worker is experiencing. Note any side effects or changes to the approved treatment plan. 

Once reviewed, return to step 2 and complete steps 2 through 6. The medical consultant reviews all requests for extensions, discharge, treatment plan modifications or clinical concerns.

In all cases, contact the worker and discuss the next steps based on the treating specialist'sA specialist physician, such as a neurologist, psychiatrist, physiatrist, or anesthesiologist who is treating the worker for the condition that ketamine is requested for. medication report and the medical consultants review. 

For claims where psychological counselling is ongoing, ensure the counselling provider is up to date with the ketamine/esketamine decisions and continue to review for an extension.