ModifiedCapital BluecrossPolicy MP 2.167

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

This policy governs coverage determinations for intravenous infusion of anesthetic agents (e.g., ketamine, lidocaine) when used to treat chronic pain syndromes and psychiatric disorders for members of Capital Blue Cross products to which the policy applies.

Policy Summary

PayerCapital Bluecross

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy MP 2.167

Change TypeMajor review — psychiatric indications addedcoding updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionDo not submit prior authorization or claims using listed codes for IV anesthetic treatment of chronic pain or psychiatric disorders; these services are investigational and not covered.

SourceLink

POLICY UPDATE CHANGES

New policy statement added to include the use of ketamine for psychiatric disorders as investigational.

Added codes 96365, 96366, and 96374 to coding table.

New HCPCS codes J2002-J2004 were added and J2001 deleted effective 10/01/2024.

investigationalcoverage stance

1–6 hrsinitial cycle duration

2–4 wksbenefit duration (ketamine)

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Coverage Criteria

Investigational — chronic pain and psychiatric indications

Not covered (investigational) when used for the treatment of chronic pain or psychiatric disorders.

Policy statement: Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of chronic pain or psychiatric disorders is considered investigational due to insufficient evidence of benefit.

Applies to chronic neuropathic pain, chronic daily headache, fibromyalgia, treatment-resistant depression, OCD, PTSD, and other psychiatric disorders as cited.

Not covered — investigational

Investigational and therefore not covered when used to report intravenous anesthetics for the treatment of chronic pain and psychiatric disorders as outlined in the policy statement:

Investigational Use: Intravenous anesthetics used for treatment of chronic pain and for psychiatric disorders (including treatment-resistant depression and other psychiatric indications) are considered investigational.

Use of the listed HCPCS/CPT codes to report these services may be subject to denial: J2002, J2003, J2004, J3490, 96365, 96366, 96374.

This policy does not address continuous subcutaneous or continuous intravenous infusions used for palliative or terminal cancer pain management. The policy scope is limited to courses of intravenous anesthetic agents (for example, bolus followed by infusion at subanesthetic doses) used in the evaluation or treatment of chronic pain syndromes and psychiatric disorders and does not apply to continuous infusion techniques for end-of-life symptom control.

Intravenous anesthetic administration for the treatment of chronic pain syndromes and psychiatric disorders is designated as investigational and therefore not covered when reported using the procedure and drug codes listed in this policy.

The available evidence from systematic reviews, randomized controlled trials, and observational studies is insufficient to demonstrate a sustained net health benefit for IV anesthetic infusions in chronic pain syndromes or psychiatric disorders. Trials of IV lidocaine have not shown durable pain relief, and trials of IV ketamine show at best transient benefit (often lasting only weeks) with concerns about study blinding, small sample sizes, and adverse events. Overall, the evidence is inadequate to conclude that repeated courses of IV anesthetics improve long-term clinical outcomes.

Accordingly, intravenous anesthetic treatments (for example, IV ketamine or IV lidocaine infusions) when used for chronic pain syndromes or for psychiatric disorders (including treatment-resistant depression, OCD, PTSD, and similar indications) are considered investigational and are not covered under this policy.

Coding

Investigational / Not covered when used to report IV anesthetics for chronic pain and psychiatric disordersmixedNot Covered

J2002
J2003
J2004
J3490
96365
96366
96374

Investigational / Not covered codes listed in policymixedNot Covered

J2002	HCPCS code listed in policy
J2003	HCPCS code listed in policy
J2004	HCPCS code listed in policy
J3490	Unclassified drug code referenced
96365	Intravenous infusion, initial; per policy coding table addition
96366	Intravenous infusion, each additional hour; per policy coding table addition
96374	Therapeutic, prophylactic, or diagnostic injection (specify), intravenous; push

Effective / administrative coding change date

Effective/administrative coding change date10/01/2024 — J2001 deleted; J2002–J2004 added

Policy history entry09/18/2024 Administrative Update: new J-codes added effective 10/01/2024

Related coding additions noted elsewhere01/10/2024: CPT codes 96365, 96366, 96374 previously added to coding table

Provider Actions and Billing Guidance

Note

Program/product variations

This policy applies to certain Capital Blue Cross programs and products; benefit variations may exist. FEP PPO members should refer to the FEP Medical Policy Manual: https://www.fepblue.org/benefit-plans/medical-policies-and-utilization-management-guidelines/medical-policies

Policy applies to certain Capital Blue Cross programs and products; benefit variations may exist
FEP PPO - refer to FEP Medical Policy Manual (link above)

Denial Risk

Prior authorization and coverage

Intravenous anesthetic administration for the treatment of chronic pain and psychiatric disorders is considered investigational and is not a covered benefit under this policy.

Not covered — investigational: IV anesthetics for chronic pain and psychiatric disorders

Background

Intravenous anesthetic agents such as ketamine and lidocaine have been reported in the literature for a range of indications including chronic daily headache, neuropathic pain, fibromyalgia, complex regional pain syndrome, and treatment-resistant psychiatric disorders. Protocols vary but often use subanesthetic bolus followed by infusion, with initial cycles described as infusions lasting approximately 1–6 hours and sometimes administered on consecutive days for up to 10 days. Potential benefits observed in some studies are typically short-lived, and significant safety concerns have been noted (for example, cardiac arrhythmias and seizures with lidocaine; dissociation, hallucinations, and respiratory depression with ketamine).

Definitions

Chronic daily headache — definition and diagnostic criteria

DefinitionChronic daily headache: headache disorder that occurs >15 days per month for at least 3 months; includes chronic migraine, new daily persistent headache, hemicranias continua, and chronic tension-type headache.

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

Included diagnosesChronic migraine, new daily persistent headache, hemicranias continua, chronic tension-type headache.

Neuropathic pain — definition and clinical features

DefinitionNeuropathic pain: pain often disproportionate to the triggering injury; may include allodynia, dysesthesia, and hyperalgesia and can persist ≥6 months.

Clinical featuresAllodynia (pain from normally nonpainful stimuli), dysesthesia (constant unpleasant/electrical sensation), hyperalgesia (exaggerated response to painful stimuli).

Conservative Treatment Requirements

Frequency Limits

Initial cycle protocols

Initial cycle protocolSubanesthetic dose infusion preceded by a bolus; infusion duration per session typically 1 to 6 hours for initial cycles.

Course durationInitial cycle protocols may be given for up to 10 days.

SettingMay be administered in inpatient or outpatient settings as part of a pain management program.

Frequency limits — additional notes

Frequency limit statementNo formal frequency limit stated in policy; initial cycles described but repeat frequency not specified.

Clinical practice noteTest infusions have been used in treatment planning to assess responsiveness prior to considering oral agents, but policy provides no frequency restrictions.

Imaging and Safety Requirements

Documentation Required

IV lidocaine safety — require baseline ECG and electrolytes

Before administering IV lidocaine, ensure the patient has normal ECG conduction and normal serum electrolyte concentrations; lidocaine IV should be given only to patients meeting these safety parameters to minimize arrhythmia risk.

Lidocaine IV associated with risk of arrhythmias and seizures; ECG and serum electrolytes required for safety assessment.

Note

Safety monitoring and provider familiarity with risks

Policy notes safety concerns for IV anesthetic administration (arrhythmia, seizures, dissociation, respiratory depression); providers must be familiar with these risks and monitor patients appropriately when administering or evaluating such therapies.

Severe adverse events for lidocaine include arrhythmias and seizures; ketamine may cause dissociation, hallucinations, or respiratory depression.
Policy designates these uses investigational due to limited benefit and significant safety concerns.

Not Covered

Intravenous infusion of anesthetics for chronic pain indications is not covered (investigational). Similarly, IV anesthetic infusions for psychiatric indications, including treatment-resistant depression and other psychiatric disorders, are also designated not covered (investigational) under this policy. Claims submitted with the policy’s listed HCPCS/CPT codes for these indications may be denied.