Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
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This policy governs coverage of intravenous ketamine and lidocaine infusions when used to treat chronic pain conditions and psychiatric disorders for Blue Cross Blue Shield of North Carolina members; it affects providers requesting reimbursement or prior authorization for these services.
No material clinical or coverage changes in this revision.
Coverage Criteria and Policy Stance
Investigational / Not covered
Covered when ALL of the following are met
Policy forbids coverage for these indications
Coverage stance and non-covered indications
Policy-level coverage stance as documented in implementation history
Supported by implementation history entries (chunks 18, 19).
Supported by implementation history entries (chunks 19, 20).
Intravenous infusion of anesthetics (for example, ketamine or lidocaine) for the treatment of chronic pain is considered investigational and is not covered. This includes, but is not limited to, use for chronic neuropathic pain, chronic daily headaches, and fibromyalgia.
Psychiatric disorders are listed among the non-covered indications for intravenous anesthetic infusions. The policy was updated to explicitly add psychiatric disorders to the non-covered list in 2019 and the policy title was changed in 2020 to reflect inclusion of psychiatric indications.
More recently, on 05/14/2025 the policy was updated to explicitly add treatment‑resistant depression and post‑traumatic stress disorder (PTSD) to the When Not Covered section.
Chronic daily headaches were added to the When Not Covered section of this policy during the 2014 update and have since been maintained as a non‑covered indication for intravenous anesthetic infusions.
The policy language reflects that chronic daily headaches are considered part of the chronic pain indications for which IV anesthetic infusions are investigational and not covered.
Historically, the policy originally stated in 2010 that intravenous infusion of anesthetics for management of chronic neuropathic pain was not recommended. Subsequent reviews in 2012 converted that guidance to an investigational designation for treatment of chronic pain.
Later updates continued to reaffirm the investigational or not‑recommended stance for IV anesthetic infusions for chronic pain and extended the non‑covered indications to include psychiatric disorders, with no change to the core policy statement that these uses are not covered.
Billing and Coding
| 96365 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); initial infusion |
| 96366 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional hour |
| 96374 | Therapeutic, prophylactic, or diagnostic injection; chemo administration, complex |
| J3490 | Unclassified drugs (used for ketamine per policy guidance) |
| J3490 | Use for Ketamine (per billing/coding section) |
Provider Requirements, Billing Instructions, and Documentation
Follow BCBSNC prior-authorization, reimbursement, and coding guidance
Follow BCBSNC prior-authorization, reimbursement, and coding guidance when submitting claims for IV anesthetic infusions; include the applicable infusion CPT codes (96365, 96366, 96374) and be prepared to supply medical records when requested.
No step therapy requirements stated in this policy
No step therapy requirements are specified in this policy document; the policy does not list any required medication or therapy trials prior to consideration of IV anesthetic infusions.
No step therapy requirements identified in update history
No step therapy requirements are specified in the cited policy sections or implementation history.
Provide complete medical records when requested
BCBSNC may request medical records to determine medical necessity; when records are requested, include all specific information needed because letters of support alone are not sufficient unless they contain the required details.
- Provide full medical records when requested for medical necessity determinations
- Letters of support/explanation are useful but not sufficient unless they include all specific information needed
Medical policy is informational; determine benefits/eligibility from the contract
This medical policy is informational only and is not an authorization, certification, explanation of benefits, or a contract; benefits and eligibility must be determined from the group contract and subscriber certificate before applying the policy.
Investigational — IV anesthetic infusions are not covered
Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of chronic pain or psychiatric disorders is considered investigational and is not covered; claims for these indications may be denied.
- Policy statement: "Intravenous anesthetics for the treatment of chronic pain and psychiatric disorders are considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures."
- Exclusion: IV infusion for chronic pain and psychiatric disorders is considered investigational
Historical designation: not recommended → investigational
Historically, IV anesthetic infusions for management of chronic pain were determined not recommended (2010) and by 2012 were classified investigational; this history supports potential claim denials for these uses.
- 8/3/10: New guideline—management of chronic neuropathic pain not recommended
- 9/18/12: Converted to corporate medical policy and considered investigational
Policy updated: psychiatric disorders listed as non‑covered
Policy implementation history documents that psychiatric disorders were added to the list of non-covered indications (added 2019) and the policy title/statement was updated on 04/28/2020 to reflect psychiatric disorders as non‑covered.
- 4/30/19: Added "psychiatric disorders" to non-covered indications
- 4/28/20: Policy title changed and statement updated to include psychiatric disorders
Background and Context
Intravenous ketamine and lidocaine have been investigated as subanesthetic infusions for a range of conditions including chronic neuropathic pain, chronic daily headache, fibromyalgia and treatment‑resistant psychiatric disorders (for example, depression and obsessive‑compulsive disorder).
Ketamine acts as an NMDA receptor antagonist with dissociative effects and potential for serious adverse events; lidocaine modulates voltage‑dependent sodium channels and carries risks such as arrhythmia and seizures. Available evidence demonstrates limited short‑term benefit in some trials but overall insufficient evidence of durable net health benefit for these indications, which contributes to the policy’s investigational classification.
Definitions and Scope
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