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 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.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeTechnical/update to referencesno material coverage change

Effective DateApr 1, 2026

Last ReviewMay 6, 2026

Next Review DateApr 1, 2026

Key ActionFollow BCBSNC prior authorization and billing guidance and supply requested medical records for coverage determination.

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

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

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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 TypeTechnical/update to referencesno material coverage change

Effective DateApr 1, 2026

Last ReviewMay 6, 2026

Next Review DateApr 1, 2026

Key ActionFollow BCBSNC prior authorization and billing guidance and supply requested medical records for coverage determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

investigational

96365/66/74codes listed

J3490ketamine billing

05/06/2026recent update

Coverage Criteria and Policy Stance

Investigational / Not covered

Covered when ALL of the following are met

Investigational policy statement: Intravenous anesthetics for the treatment of chronic pain and psychiatric disorders are considered investigational for all applications and BCBSNC does not provide coverage for investigational services or procedures.

Policy forbids coverage for these indications

Coverage stance and non-covered indications

Policy-level coverage stance as documented in implementation history

Investigational/Not Recommended: Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for chronic pain was initially described as not recommended in 2010 and by 2012 was considered investigational for treatment of chronic pain, including neuropathic pain and fibromyalgia.

Supported by implementation history entries (chunks 18, 19).

Non-covered Indications: 'Psychiatric disorders' were added to the list of non-covered indications in 2019–2020; treatment-resistant depression and post‑traumatic stress disorder were explicitly added to the when-not-covered section in 2025.

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

Applicable codesmixed

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)

Billing/Coding guidanceHCPCS

J3490

Use for Ketamine (per billing/coding section)

Provider Requirements, Billing Instructions, and Documentation

Prior Authorization

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.

Applicable infusion CPT codes: 96365, 96366, 96374
Follow reimbursement/authorization guidance on bcbsnc.com

Billing Rule

Use J3490 for ketamine billing

When billing for ketamine administered IV, report HCPCS/CPT code J3490 (Unclassified drugs) as directed in the Billing/Coding section.

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

Chronic daily headache — definition and diagnostic frequency criteria

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

Diagnostic frequency threshold≥15 headache days per month for >3 months.

Included subtypesChronic migraine; new daily persistent headache; hemicranias continua; chronic tension-type headache.

Off-label use — IV ketamine for chronic pain or psychiatric disorders described as off-label

Policy characterizationIV ketamine for the treatment of chronic pain or psychiatric disorders is described as an off-label use.

Implication for coverage

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeTechnical/update to referencesno material coverage change

Effective DateApr 1, 2026

Last ReviewMay 6, 2026

Next Review DateApr 1, 2026

Key ActionFollow BCBSNC prior authorization and billing guidance and supply requested medical records for coverage determination.

SourceLink

On This Page

Use CPT/HCPCS code J3490 for Ketamine

Step Therapy

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.

Step Therapy

No step therapy requirements identified in update history

No step therapy requirements are specified in the cited policy sections or implementation history.

Documentation Required

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

Note

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.

Denial Risk

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

Denial Risk

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

Denial Risk

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

Intravenous infusion of anesthetics (e.g., ketamine) for chronic pain and psychiatric disorders is considered investigational and not covered under this policy.

Policy history noteStatement clarifying IV ketamine as an off‑label use was added 2/24/17.