ModifiedCapital BluecrossPolicy MP 2.167

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Governs coverage for intravenous infusion of anesthetic agents (e.g., ketamine, lidocaine) for chronic pain syndromes and psychiatric disorders; states these uses are investigational and not covered, with noted product variations.

Policy Summary

PayerCapital Bluecross

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

Policy CodePolicy MP 2.167

Change TypeMajor Reviewcoding additions (HCPCS and CPT) and investigational scope expanded to psychiatric disorders

Effective Date01/01/2026

Next Review Date

Key ActionVerify member benefits and eligibility and anticipate noncoverage for IV anesthetic infusions billed with the listed codes.

SourceLink

POLICY UPDATE CHANGES

Policy statement was expanded to include the use of ketamine for psychiatric disorders as investigational.

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

CPT codes 96365, 96366, and 96374 were added to the coding table.

investigationalcoverage stance

1/1/2026effective date

MP 2.167policy #

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Coverage Criteria

Investigational / Not Medically Necessary

Not covered when used for the following

Investigational uses: Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of chronic pain (including, but not limited to, chronic neuropathic pain, chronic daily headache, and fibromyalgia) is considered investigational.

There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Investigational uses - psychiatric disorders: Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of psychiatric disorders (including, but not limited to, treatment-resistant depression, obsessive-compulsive disorder, and post-traumatic stress disorder) is considered investigational.

There is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Investigational / Not Covered

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 — billed codes: Use of intravenous anesthetic agents billed with the listed HCPCS/CPT codes (J2002, J2003, J2004, J3490, 96365, 96366, 96374) for the treatment of chronic pain and psychiatric disorders is considered investigational and not covered.

Codes shown in coding table apply.

This policy does not address continuous subcutaneous or continuous intravenous infusions of anesthetic agents used for management of terminal or end-of-life pain (for example, continuous infusions for terminal cancer pain). The scope is limited to intermittent courses of intravenous anesthetic infusions (e.g., subanesthetic ketamine or systemic lidocaine) used for chronic pain syndromes and psychiatric disorders, and continuous subcutaneous or continuous IV infusion paradigms for palliative/terminal care are not discussed in this document.

No additional exclusions are specified beyond the investigational stance and the list of HCPCS/CPT codes in the coding section. Uses of the listed codes for intravenous anesthetic administration to treat chronic pain or psychiatric disorders are described in the policy as investigational and not covered.

Available evidence includes systematic reviews, randomized controlled trials, and observational studies, but overall is insufficient to establish a durable net health benefit for intravenous anesthetic infusions in chronic pain or psychiatric disorders. Trials of IV lidocaine have generally failed to show durable pain relief; small ketamine RCTs suggest only short-term improvement (often 2–4 weeks) and suffer from methodological limitations (lack of active controls, risk of unblinding). For psychiatric indications, short‑term symptom improvement has been reported after single or repeated ketamine infusions, but effects are transient, evidence is limited beyond single infusions, and safety concerns and variable trial results prevent concluding a sustained benefit.

Intravenous anesthetics billed with the HCPCS/CPT codes listed in the coding section (for example, J2002–J2004, J3490, 96365, 96366, 96374) for treatment of chronic pain or psychiatric disorders are considered investigational and are therefore not covered. Providers should expect that claims reporting these administrations for the listed indications will be denied as not medically necessary per this policy.

Coding

Investigational / Not covered codes listedHCPCS | CPTNot Covered

J2002
J2003
J2004
J3490
96365
96366
96374

Investigational / Not Covered codesmixedNot Covered

J2002	HCPCS code listed in policy (specific drug administration code as cited)
J2003	HCPCS code listed in policy (specific drug administration code as cited)
J2004	HCPCS code listed in policy (specific drug administration code as cited)
J3490	Unclassified drugs (listed)
96365	Intravenous infusion, initial, therapeutic, prophylactic, or diagnostic; up to 1 hour
96366	Intravenous infusion, each additional hour
96374	Therapeutic, prophylactic, or diagnostic injection (specify substance)

inv-09: Initial infusion duration — subanesthetic doses for 1 to 6 hours for up to 10 days

Initial infusion protocolSubanesthetic infusions given after a bolus; initial cycle may include subanesthetic doses for 1 to 6 hours per infusion for up to 10 days.

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

Bolus useA bolus infusion may precede the subanesthetic infusion to achieve desired blood levels sooner.

inv-10: Coding — miscellaneous/empty key-value placeholder from inventory

Placeholder — coding groupPolicy lists investigational/not-covered procedure codes (see coding table).

Codes referenced

Provider Actions & Billing Implications

Prior Authorization

Product variation / prior authorization note

This policy may not apply to all Capital Blue Cross products. Coverage and prior authorization requirements can vary by member benefit plan and product. Check product-specific policy variations (for example, FEP PPO references the FEP Medical Policy Manual) before assuming applicability.

Note

Benefit and eligibility verification

Providers should verify the member’s benefit design and eligibility for the date of service prior to providing services. Medical policy determinations do not guarantee coverage or payment; final claim payment is subject to the member’s contract terms, limitations, and exclusions.

Denial Risk

Investigational use — denial risk and documentation

Background

IV lidocaine and ketamine have been used off‑label for a variety of chronic pain syndromes (including neuropathic pain, chronic daily headache, and fibromyalgia) and for psychiatric disorders (including treatment‑resistant depression, obsessive‑compulsive disorder, and post‑traumatic stress disorder). Dosing protocols in the literature commonly use subanesthetic infusions lasting 1 to 6 hours, sometimes administered over repeated days (reports up to 10 days), but evidence shows limited durability of benefit and identifies significant risks — for example, cardiac arrhythmia concerns with lidocaine and psychological or respiratory adverse effects with ketamine.

Definitions

inv-20: Chronic daily headache definition — >15 days/month for at least 3 months; includes chronic migraine, new daily persistent headache, etc.

DefinitionChronic daily headache: headache disorder occurring >15 days/month for at least 3 months.

Included subtypesIncludes chronic migraine, new daily persistent headache, hemicrania continua, and chronic tension-type headache.

Duration criterionSymptoms must be present for at least 3 months to meet the definition.

inv-21: CRPS definition — Complex Regional Pain Syndrome description and subtypes

DefinitionComplex Regional Pain Syndrome (CRPS) is a chronic pain syndrome with two forms: CRPS 1 (replaces reflex sympathetic dystrophy) and CRPS 2 (replaces causalgia).

Typical presentationOccurs most often in the arms or legs after a minor or major injury and is associated with severe pain and increased sensitivity to touch in the affected limb.

Conservative Treatment Requirements

Frequency Limits

inv-25: IV anesthetic infusion courses — repeat courses have limited evidence and short durability; no frequency limits provided because therapy is investigational

Evidence on repeat coursesRepeat courses of IV anesthetic infusions have limited evidence and short durability of benefit; additional trials needed to evaluate long-term efficacy and safety.

Frequency limitsNo frequency limits are specified in the policy because the therapy is considered investigational.

Net health outcomeOverall evidence is insufficient to determine an improvement in net health outcome for repeat courses.

inv-26: Frequency limits — empty/placeholder key-value per inventory

Frequency limits — placeholderNo frequency limits specified; inventory placeholder only.

Policy stance

Imaging / Monitoring Requirements

Documentation Required

Obtain ECG and confirm normal electrolytes before IV lidocaine

Before administering IV lidocaine, confirm the patient has normal electrocardiographic conduction and normal serum electrolyte concentrations to minimize risk of cardiac arrhythmias.

Lidocaine should only be given intravenously to patients with normal conduction on electrocardiography.
Verify normal serum electrolyte concentrations prior to IV lidocaine administration.

Documentation Required

Document required monitoring (ECG/electrolytes) when providing IV anesthetics

Monitoring and imaging requirements referenced in the policy (e.g., ECG for lidocaine) must be followed where clinically indicated; document monitoring in the medical record.

Policy specifies ECG and serum electrolyte assessment prior to IV lidocaine.
Document monitoring and clinical assessments in the medical record; policies do not replace clinical judgment.

Not Covered

Intravenous infusion of anesthetic agents (e.g., ketamine or lidocaine) for treatment of chronic pain conditions (including neuropathic pain, chronic daily headache, fibromyalgia) and for psychiatric disorders (including treatment‑resistant depression, OCD, PTSD) is considered investigational and therefore not covered when billed with the HCPCS/CPT codes listed in the policy. Claims submitted using these codes for these indications may be denied as investigational/not medically necessary.