Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
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This policy defines Blue Cross Blue Shield of North Carolina's coverage stance on intravenous (IV) anesthetic infusions (eg, ketamine, lidocaine) when used to treat chronic pain conditions and psychiatric disorders, and is intended for providers and claims reviewers contracting with BCBSNC.
No material clinical or coverage changes in this revision.
Coverage determinations
Investigational / Not Covered Criteria
Covered when ALL of the following are met:
ALL of the following
- Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of chronic pain or psychiatric disorders is considered investigational and is not covered.
- Non-covered examples include chronic neuropathic pain, chronic daily headaches, fibromyalgia, treatment-resistant depression, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).
- No applicable covered indications are listed in this policy.
- Clinical evidence includes randomized controlled trials, systematic reviews, and observational studies that demonstrate limited durability of benefit and potential for adverse events, resulting in insufficient evidence of net health benefit for these indications.
ALL of the following
- Inclusion of CPT/HCPCS codes in the policy does not guarantee reimbursement; BCBSNC may request medical records to determine medical necessity.
ALL of the following
- IV ketamine for the treatment of chronic pain or psychiatric disorders is an off-label use.
ALL of the following
- Ketamine has dissociative and cardiorespiratory risks; lidocaine has systemic cardiac risks. These safety concerns contribute to the investigational determination.
ALL of the following
- Professional society guidance notes limited or weak evidence and emphasizes risks and data limitations for ketamine use in psychiatric and pain disorders.
ALL of the following
- BCBSNC does not provide coverage for intravenous anesthetic infusions (eg, ketamine, lidocaine) when used to treat chronic pain conditions or psychiatric disorders.
Coverage statements and administrative history
Policy-level coverage stance and administrative history:
ALL of the following
- 8/3/2010: Evidence-based guideline stating IV infusion of anesthetics (eg, ketamine or lidocaine) for management of chronic neuropathic pain is not recommended.
- 9/18/2012: Evidence-based guideline converted to corporate medical policy; IV anesthetic infusions for treatment of chronic pain (including neuropathic pain and fibromyalgia) considered investigational.
ALL of the following
- 1/10/2012: Removed the word 'neuropathic' from the policy title and text where appropriate; intent unchanged.
- 4/30/2019 and 4/28/2020: 'Psychiatric disorders' added to list of non-covered indications and incorporated into the policy title; policy statement updated to reflect existing 'when not covered' language.
ALL of the following
- 5/14/2025: 'When not covered' list updated to include treatment-resistant depression and post-traumatic stress disorder (PTSD).
ALL of the following
- 5/2/2023: Added billing guidance 'Use CPT code J3490 for Ketamine' to the billing/coding section.
- 5/14/2025: Removed deleted code J2001 from Billing/Coding section as part of updates.
ALL of the following
- 2/24/2017: Clarified that IV ketamine for treatment of chronic pain or psychiatric disorders is an off-label use.
ALL of the following
- Multiple Specialty Matched Consultant Advisory Panel reviews and Medical Director reviews occurred between 2010 and 2025 with no change to the policy statement regarding investigational status.
Billing and coding guidance
| J3490 | Unclassified drugs – guidance to use for Ketamine per policy update 5/2/23 |
Provider responsibilities, documentation, and billing
Provide medical records on request; code listing is not a guarantee of payment
BCBSNC may request medical records to determine medical necessity; inclusion of a code in the policy does not guarantee reimbursement. When records are requested, letters of support or explanation may be useful but are not sufficient unless they include all specific information needed for the medical necessity determination.
- Inclusion of a code does not guarantee it will be reimbursed.
- BCBSNC may request medical records to determine medical necessity.
- Letters of support/explanation are not sufficient documentation unless they include all required information.
Definitions and condition descriptions
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