CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

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.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeAdministrative review — no material coverage changes

Effective DateApr 1, 2026

Last ReviewMay 14, 2025

Next Review DateApr 1, 2026

Key ActionBCBSNC may request medical records to determine medical necessity; inclusion of codes does not guarantee reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Investigational

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CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - North Carolina policy alerts

Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeAdministrative review — no material coverage changes

Effective DateApr 1, 2026

Last ReviewMay 14, 2025

Next Review DateApr 1, 2026

Key ActionBCBSNC may request medical records to determine medical necessity; inclusion of codes does not guarantee reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Investigational

96365/96366/96374billing/coding examples

J3490ketamine billing note

Orig:2010policy timeline

Expandedtitle change

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.

Source support

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

Billing and coding guidance

Applicable codes (inclusion not guarantee of payment)CPT | HCPCS | mixed

96365	Therapeutic, prophylactic, or diagnostic intravenous infusion; initial, up to 1 hour
96366	each additional hour
96374	Therapeutic, prophylactic, or diagnostic injection (specify substance)
J3490	Unclassified drugs (used for ketamine per policy note)

Ketamine billing guidanceHCPCS

J3490

Unclassified drugs – guidance to use for Ketamine per policy update 5/2/23

Provider responsibilities, documentation, and billing

Documentation Required

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.

Billing Rule

Report ketamine using CPT code J3490

Definitions and condition descriptions

inv-07: Treatment-resistant depression — definition and context for IV ketamine investigation

DefinitionDepression that does not respond adequately to appropriate courses of antidepressant medications; IV ketamine has been investigated for this condition.

Context — policy statusBCBSNC considers IV anesthetic infusions (eg, ketamine) investigational and not covered for treatment-resistant depression.

Clinical noteIV ketamine has been investigated as a subanesthetic infusion (bolus followed by 1–6 hour infusions up to 10 days) for treatment-resistant depression.

inv-08: Chronic daily headache — definition and examples

DefinitionHeadache disorder that occurs 15 or more days a month for more than 3 months; includes chronic migraine, new daily persistent headache, hemicrania continua, and chronic tension-type headache.

Examples—related indications

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeAdministrative review — no material coverage changes

Effective DateApr 1, 2026

Last ReviewMay 14, 2025

Next Review DateApr 1, 2026

Key ActionBCBSNC may request medical records to determine medical necessity; inclusion of codes does not guarantee reimbursement.

SourceLink

On This Page

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 guidance added: use CPT code J3490 to report ketamine.

Policy billing/coding section explicitly states: Use CPT code J3490 for Ketamine.
This guidance was added to the billing/coding section on 5/2/23.

IV infusion of anesthetics (eg, ketamine or lidocaine) has been investigated for migraine and chronic daily headache.

inv-09: Neuropathic pain — definition and example conditions (PHN, CRPS, diabetic neuropathy)

DefinitionPain often disproportionate to the triggering injury and may include allodynia, dysesthesia, and/or hyperalgesia; symptoms may persist ≥6 months after illness or injury.

Example conditionsPost‑herpetic neuralgia (PHN), complex regional pain syndrome (CRPS), diabetic neuropathy, phantom limb pain.

Treatment contextIV lidocaine or ketamine at subanesthetic doses has been examined for chronic neuropathic pain, but BCBSNC considers these uses investigational and not covered.

inv-10: Off-label use (IV ketamine) — statement that IV ketamine for chronic pain or psychiatric disorders is off-label

StatementIV ketamine for the treatment of chronic pain or psychiatric disorders is an off‑label use.

Regulatory contextKetamine hydrochloride injection is FDA‑approved for diagnostic and surgical anesthesia indications, but not for chronic pain or psychiatric disorders.

Policy clarificationBCBSNC clarified the off‑label status of IV ketamine for chronic pain or psychiatric disorders (clarified 2/24/17) and subsequently included psychiatric disorders in the policy scope.