CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

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.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionFile claims using an unlisted HCPCS drug code(s); IV ketamine or lidocaine infusions for chronic pain or psychiatric disorders are not covered or are considered not medically necessary and may be denied.

SourceLink

Not coveredChronic pain (Commercial)

Not coveredPsychiatric disorders (Commercial)

Not coveredChronic pain (Medicare Advantage)

Not coveredPsychiatric disorders (Medicare Advantage)

Coverage determinations for IV ketamine and lidocaine

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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

HCPCS / billing instructionHCPCS

unlisted

No specific HCPCS code; claims should be filed using an unlisted HCPCS drug code for these treatments

Documentation Required

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

Denial Risk

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

Definitions

Chronic daily headacheHeadache disorder occurring more than 15 days a month for at least 3 months; includes chronic migraine, new daily persistent headache, hemicranias continua, and chronic tension-type headache.

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

Treatment-resistant depressionDepression that does not respond adequately to appropriate courses of antidepressant medications.

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.