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, go to step 2.

If the worker may be eligible for ketamine/esketamine treatment IV ketamine, esketamine, psychedelic-assisted psychotherapy , review the written request and applicationApplication for trial of ketamine (C1520) is required for consideration of IV ketamine, esketamine, or psychedelic-assisted psychotherapy (PAP) therapy or treatment resistant depression. from the treating specialistNeurologist, psychiatrist, physiatrist, chronic pain specialist(s). Confirm the required documentation is completed and received: 

• Application form.
• Informed consent.
• Instruction to not drive for 24 hours following the treatment.
• Compliance with required monitoring, and reporting of outcome measures as defined by WCB.
• Baseline complete psychiatric and medical assessment with physical exam and current weight.
• Documented confirmation of the absence of contraindications is required, with detail as appropriate. 

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 a written recommendation and application form indicating 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. 

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 and chronic pain specialist) contact the requestor and send the Request for Ketamine Treatment Information letter educating them on the requirements for ketamine/esketamine to be considered.   

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

• the injuries and/or conditions accepted and not accepted on the claim are up to date.
• all other conventional medical aid that was tried or at least considered and found to be medically inappropriate is identified for the medical consultant to review.
• all information related to the proposed treatment is available for review as outlined in step 1 (e.g., medical reports, applicationApplication form C1520 is required for consideration of IV ketamine, esketamine, treatment resistant depression or psychedelic-assisted psychotherapy (PAP) therapy. form, client consent, etc.).
• any known risks or contraindications specific to the worker are identified in the referral (risks may include other medical conditions such as:
  • Hypersensitivity to ketamine or esketamine.
  • History of substance use disorders.
  • History of a medical condition that is unstable or is at risk of becoming unstable due to an increase in blood pressure or intracranial pressure during treatment (such as uncontrolled hypertension, heart failure, coronary artery disease or previous heart attack or stroke, history of intracerebral hemorrhage, or aneurysmal vascular disease).  

Once all the information is available for review, make the referral to the internal medical consultant. If any contraindications are identified, ensure these are noted in the referral. 

The medical consultant will review the initial/extension request for the ketamine/esketamine treatment and provide 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 report. If the consultation report requires clarification, reach out to the medical consultant who recommended the psychiatric expedited specialist consultation. 

When the specialist’s report:  

• Supports the proposed treatment as recommended, continue to the next step.
• Supports the proposed treatment with modifications, reach out to the medical consultant for clarification. The medical consultant may contact the specialist to discuss the modified treatment plan to ensure it remains medically reasonable. Following the review, if the medical consultant,
  • supports the modified treatment plan, continue to the next step.
  • does not support the modified treatment plan, continue to step 6 to communicate the decision.  
• Does not support the proposed treatment, continue to step 6 to communicate the decision. 

Send a recommendation to the supervisor requesting approval for the proposed treatment. 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.
• Estimated cost for the proposed treatment and the initial trial period that will be covered.
• 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 decision 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: 

• Explain the length of time the treatment is approved and discuss 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. If the administering clinic has not provided the detailed treatment plan, gather this information from the clinic prior to sending a letter to the worker.
• Ensure the treatment provider is aware of the monitoring requirements during the administration of ketamine/esketamine, including baseline and periodic vital signs (level of consciousness, oxygen saturation, respiration rate, BP and pulse), and that treatment must take place in a medical facility with trained staff available to manage any neurological, psychiatric or cardiorespiratory side effects.
• 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 an extension request was reviewed and the worker:

• meets the criteria for an extension, explain that authorization will be provided based on the medical consultant's recommendations with reviews every three months to ensure the worker continues to meet the criteria for approval. 
• does not meet the criteria for an extension, explain why they no longer meet all of the criteria. Document the discussion and communicate the decision in writing. 

When an extension is approved, go to Step 7. 

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.  

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.  

The treating specialist must provide an updated medication report 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 the medication report from the treating specialist 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. 

When the medication report indicates a change in the treatment plan or a treatment extension is recommended, return to step 2 and repeat steps 2 through 6.  

When the medication report indicates the worker:   

• is not making progress or experiencing any benefit from the treatment,
• is experiencing side effects or a contraindication to continue with treatment arises, or
• has been discharged or an extension of treatment has not been recommended, 

discontinue ketamine/esketamine treatment and do not continue further with this procedure. Continue to manage the claim and consider alternative treatment options. 

In all cases, contact the worker and discuss the next steps based on the treating specialist’s medication report. 

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.