CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Intravenous Anesthetics

Policy governing coverage stance for intravenous infusions of anesthetic agents (for example, ketamine or lidocaine) when used to treat chronic pain syndromes, fibromyalgia, chronic headache disorders, and psychiatric disorders; applies to Medicare Advantage and commercial product lines administered by BCBS Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIntravenous Anesthetics

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 23, 2011

Next Review DateN/A

Key ActionDo not submit claims expecting coverage for IV ketamine or lidocaine infusions for chronic pain or psychiatric disorders; these are not covered or are not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

not coveredCoverage stance for IV anesthetic infusions for chronic pain and psychiatric disorders

no prior authPrior authorization requirement

off-labelOff-label use

unlisted HCPCSClaims coding

Coverage Criteria

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Medicare Advantage - Not Covered

Medicare Advantage coverage stance

Medicare Advantage - Not Covered: Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of chronic pain (including, but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia) or psychiatric disorders (including but not limited to depression and obsessive-compulsive disorder) is not covered because the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial - Not Medically Necessary

Commercial product coverage stance

Commercial - Not Medically Necessary: Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of chronic pain (including, but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia) or psychiatric disorders (including but not limited to depression and obsessive-compulsive disorder) is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

Claims should be filed using an unlisted HCPCS drug code(s).

This policy does not address continuous subcutaneous or continuous IV anesthetic infusions used for end-of-life or terminal cancer pain management. It applies specifically to intravenous infusion of anesthetic agents such as ketamine and lidocaine when used for the treatment of chronic pain syndromes and related disorders; these IV administrations are described in practice as a subanesthetic bolus followed by infusion for hours up to multiple days. Both agents have known and potentially serious adverse effects (for example, lidocaine-associated cardiac arrhythmias and ketamine-associated respiratory depression and psychotomimetic effects), so appropriate monitoring (eg, ECG and electrolyte assessment for lidocaine) is expected during administration.

For commercial products administered by Blue Cross Blue Shield of Rhode Island, intravenous infusion of anesthetics (for example, ketamine or lidocaine) for chronic pain conditions — including but not limited to chronic neuropathic pain, chronic daily headache, and fibromyalgia — is considered not medically necessary because the evidence is insufficient to determine effects on health outcomes. The same stance applies to IV infusions of these agents for psychiatric disorders (for example, treatment‑resistant depression and obsessive‑compulsive disorder). Claims for these services should be filed using an unlisted HCPCS drug code(s) and benefits are determined by the member’s contract.

Provider Actions and Notes

Prior Authorization

Prior authorization

Not applicable

Step Therapy

Step therapy / sequencing

None specified. Background notes mention that test infusions may be used in treatment planning and that initial treatment protocols can include subanesthetic infusions for 1–6 hours for up to 10 days, but the policy does not impose any step therapy or sequencing requirements for coverage.

Billing Rule

Claims & billing notes

Claims should be filed using an unlisted HCPCS drug code(s) as there is no specific HCPCS code for these services. Benefits and coverage may vary by group/contract; refer to the Evidence of Coverage or Subscriber Agreement for applicable coverage details.

File claims with unlisted HCPCS drug code(s)
Verify member benefits in Evidence of Coverage / Subscriber Agreement

Denial Risk

Coverage denial risk

Intravenous anesthetic infusions (eg, ketamine or lidocaine) for the treatment of chronic pain (including chronic neuropathic pain, chronic daily headache, fibromyalgia) or for psychiatric disorders (including depression and obsessive-compulsive disorder) are considered not covered / not medically necessary due to insufficient evidence.

Imaging and Monitoring Requirements

Documentation Required

Monitoring and safety requirements for IV anesthetic infusions

When IV anesthetics are administered, monitor cardiac conduction and relevant laboratory values; specifically, ensure normal ECG conduction and normal serum electrolytes before IV lidocaine to reduce risk of arrhythmia.

Lidocaine should only be given IV to patients with normal conduction on electrocardiography and normal serum electrolyte concentrations.
IV anesthetic administration may require careful titration of subanesthetic doses to reduce adverse events (eg, arrhythmia, seizures, respiratory depression with ketamine).

Definitions

Chronic daily headache — definition

DefinitionHeadache disorder occurring >15 days per month for at least 3 months; includes chronic migraine, new daily persistent headache, hemicrania continua, and chronic tension-type headache.

Minimum durationOccurs more than 15 days per month for at least 3 months.

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

Clinical contextMay be evaluated in consideration of IV anesthetic trials (eg, test infusions) but policy addresses these uses as not covered/not medically necessary for chronic headache indications.

Neuropathic pain — definition

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

Key featuresAllodynia (pain from nonpainful stimuli), dysesthesia (ongoing unpleasant/electrical sensation), and hyperalgesia (exaggerated response to painful stimuli).

Typical durationSymptoms may continue longer (eg, ≥6 months) than clinically expected after an illness or injury.

PathophysiologyAssociated with peripheral afferent sensitization, neurogenic inflammation, sympathetic coupling, and central sensitization/reorganization of somatosensory, motor, and autonomic circuits.

Background

Intravenous lidocaine and ketamine have been investigated as treatments for a range of chronic conditions including chronic neuropathic pain, chronic daily headache, fibromyalgia, and certain psychiatric disorders (eg, treatment‑resistant depression, obsessive‑compulsive disorder). Protocols commonly use a subanesthetic bolus followed by a continuous infusion for periods ranging from hours to several days. Lidocaine’s mechanism involves blockade of voltage‑dependent sodium channels and it carries risks including arrhythmias and seizures; ketamine is an N‑methyl‑d‑aspartate receptor antagonist, is a Schedule III controlled substance, and can cause respiratory depression and psychotomimetic effects. Overall, evidence is considered insufficient to demonstrate benefit of IV anesthetic infusions for these chronic indications.

OpenPayer

Intravenous Anesthetics

Coverage Criteria

Coding and Billing Guidance

Provider Actions and Notes

Conservative Treatment Requirements

Imaging and Monitoring Requirements

Definitions

Background

Not Covered