Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
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Defines BCBSRI coverage stance for IV infusion of anesthetics (eg, ketamine, lidocaine) when used to treat chronic pain syndromes and psychiatric disorders for Medicare Advantage and Commercial products.
Coverage determinations for IV ketamine and lidocaine
Coverage determination — Medicare Advantage
Intravenous infusion of anesthetics (eg, ketamine or lidocaine) is
ALL of the following
- Not covered for the treatment of chronic pain (including but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia) because evidence is insufficient to determine effects on health outcomes
- Not covered for the treatment of psychiatric disorders (including but not limited to treatment-resistant depression, OCD, PTSD) because evidence is insufficient to determine effects on health outcomes
Coverage determination — Commercial products
Intravenous infusion of anesthetics (eg, ketamine or lidocaine) is
ALL of the following
- Considered not medically necessary for the treatment of chronic pain (including but not limited to chronic neuropathic pain, chronic daily headache, fibromyalgia) due to insufficient evidence of net health benefit
- Considered not medically necessary for the treatment of psychiatric disorders (including but not limited to treatment-resistant depression, OCD, PTSD) due to insufficient evidence of net health benefit
Billing instructions and code guidance
| unlisted | No specific HCPCS code; claims should be filed using an unlisted HCPCS drug code for these treatments |
Claims billing using unlisted HCPCS code
There is no specific HCPCS code(s) for this service; claims should be filed using an unlisted HCPCS drug code(s) for the treatments noted in this policy.
Actions, denial risk, and documentation impact
Not medically necessary / not covered risk
Intravenous infusion of ketamine or lidocaine for chronic pain or psychiatric disorders is considered not medically necessary for Commercial products and not covered for Medicare Advantage; services may be denied based on the medical policy determination.
- Commercial Products: “considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.”
- Medicare Advantage Plans: “is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.”
Clinical and evidence context
Intravenous (IV) infusion of anesthetics such as lidocaine and ketamine has been evaluated for a range of off-label indications including chronic neuropathic pain, chronic daily headache, fibromyalgia, and several psychiatric disorders (eg, treatment-resistant depression, obsessive-compulsive disorder, post-traumatic stress disorder). Randomized trials and observational studies identify only short-term or inconsistent symptom improvement for some patients, with limited durability of benefit (eg, relief lasting days to a few weeks in some trials) and mixed or negative results in others.
The published evidence raises concerns about the net health benefit of IV anesthetic infusions for these indications. Many trials lacked active controls, increasing the possibility of placebo effects or unblinding; sample sizes were often small and follow-up short. In chronic pain trials, several randomized studies of IV lidocaine failed to show durable benefit and ketamine trials provided only limited, transient relief in some settings. For psychiatric indications, short-term improvements have been reported after ketamine infusions, but effects typically diminish over weeks and large controlled data demonstrating sustained benefit are lacking.
Safety considerations are important: both agents have notable adverse event profiles. Ketamine commonly causes headache, anxiety, dissociation, nausea, and dizziness and carries risks related to psychological effects and respiratory depression; lidocaine adverse events range from mild neurologic symptoms to severe cardiac arrhythmias, seizures, or loss of consciousness. The intensity of treatment protocols, severity of adverse events, and limited treatment durability contribute to insufficient evidence that repeat courses improve long-term health outcomes for these off-label uses.
Defined terms used in this policy
Policy dates and review history
Effective date: 03/01/2025. Policy last reviewed: 11/20/2024. Next routine review: not specified.
This policy applies to IV infusion of anesthetics (eg, ketamine, lidocaine) as described in the overview and background sections and includes billing guidance that there is no specific HCPCS code for these services; claims should be filed using an unlisted HCPCS drug code.
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