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Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders
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This policy defines Premera Bluecross's coverage stance on intravenous infusion of anesthetic agents (notably ketamine and lidocaine) when used to treat chronic pain syndromes or psychiatric and substance use disorders, and describes coding and evidence considerations for providers.
IV ketamine is considered investigational in any setting or in conjunction with any other service, not just when it is either monotherapy or in conjunction with psychotherapy.
In addition to IV ketamine, any office visits, clinic visits, psychotherapy sessions, evaluation and management sessions, or any other sessions during which IV ketamine is administered are also considered investigational.
HCPCS code J2001 was removed from the policy (termed October 1, 2024).
Coverage Criteria and Policy Stance
Investigational / Not covered with criteria
Intravenous infusion of anesthetics for the following indications is considered investigational:
Supported by policy statement; see chunk 3.
Supported by policy statement; see chunk 3.
Investigational (Not Covered) — IV ketamine and associated services
IV ketamine and associated services are considered investigational under the following clarified policy statements:
Clarification effective 07/01/26 expanded previous wording; see history and policy statement (chunks 32 and 3).
This policy designates intravenous (IV) infusion of anesthetic agents for the treatment of chronic pain syndromes and psychiatric or substance use disorders as investigational. Specifically, IV ketamine for depression, anxiety, other psychiatric symptoms or disorders, substance use disorders, and/or chronic pain is considered investigational, including when provided as ketamine-assisted psychotherapy. The policy also designates IV infusion of other anesthetics (for example, lidocaine) for chronic pain indications (including chronic neuropathic pain, chronic daily headache, and fibromyalgia) as investigational.
Claims involving these investigational services may be denied because the policy does not support coverage for these uses; see the coding and provider-action sections for billing guidance and documentation expectations.
This medical policy does not apply to Medicare Advantage. Members and providers should consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply under a given benefit plan.
The available evidence includes systematic reviews, randomized controlled trials, and observational studies for IV anesthetic infusions (ketamine and lidocaine) in chronic pain and various psychiatric disorders. For chronic pain, randomized trials of IV lidocaine have not demonstrated a durable benefit; limited randomized evidence for IV ketamine shows only transient symptom relief (typically 2–4 weeks) in some small trials, and some trials used no active control raising concern for placebo effects. For treatment‑resistant depression and other psychiatric disorders, studies report short‑term improvements but are limited by small sizes, variable controls, and short durability of effect. Across conditions, treatment protocols can be intensive, adverse events are common (e.g., headache, anxiety, dissociation, nausea, dizziness), and long‑term safety and effectiveness of repeat courses remain uncertain. Overall, the evidence is insufficient to determine that IV anesthetic infusions improve net health outcomes for the covered indications.
The policy clarification expands the investigational designation: IV ketamine in any setting or when given in conjunction with any other service is investigational. In addition, the policy explicitly includes as investigational any associated office visits, clinic visits, psychotherapy sessions, evaluation and management encounters, or any other sessions during which IV ketamine is administered. These associated visits or sessions are not supported for coverage when they occur in the context of IV ketamine administration.
Procedure and Supply Codes
| 0820T | Continuous in-person monitoring and intervention (e.g., psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; first physician or other qualified health care professional, each hour. |
| 0821T | Continuous in-person monitoring and intervention (e.g., psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; second physician or other qualified health care professional, concurrent with first physician or other qualified health care professional, each hour (List separately in addition to code for primary procedure). |
| 0822T | Continuous in-person monitoring and intervention (e.g., psychotherapy, crisis intervention), as needed, during psychedelic medication therapy; clinical staff under |
| 96365 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour. |
| 96366 | Each additional hour (list separately in addition to code for primary procedure). |
| 96374 | Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug. |
| J3490 | Unclassified drugs |
| J2001 | Termed/removed from policy effective October 1, 2024 |
Provider Guidance and Billing Actions
Billing: submit specific infusion and monitoring codes; investigational services may not be covered
Submit the appropriate procedure and drug codes on claims for any IV anesthetic infusion and related monitoring/psychotherapy services; the policy lists CPT codes 0820T, 0821T, 0822T, 96365, 96366, 96367, 96374 and HCPCS J3490 as relevant. Note that services described in the policy are designated investigational and may not meet coverage criteria.
- Use CPT 0820T, 0821T, 0822T for continuous in-person monitoring/intervention during psychedelic medication therapy (each hour).
- Use CPT 96365 (initial IV infusion up to 1 hour) and 96366 (each additional hour) or 96374 (IV push) as appropriate.
- Report HCPCS J3490 for unclassified drugs when applicable.
- Services are investigational per policy and may be denied despite coding.
Recommend benefit verification / prior authorization check
Verify member benefits and consider prior authorization/benefit check before scheduling IV anesthetic infusions because coverage is subject to member benefit limits and verification is recommended.
- Consult the member benefit booklet or contact a member service representative to determine whether the service is covered under the specific plan.
Document alternative/conventional treatments tried or considered before investigational IV anesthetic use
Document that conventional/standard therapies were considered or tried when relevant — the policy references alternative treatments (e.g., neuropathic pain medications such as pregabalin, non‑narcotic pain relievers, low‑dose antidepressants) as typical management for conditions like fibromyalgia and neuropathic pain.
- For fibromyalgia, note trials of neuropathic pain medications (e.g., pregabalin), non‑narcotic analgesics, or low‑dose antidepressants.
- For neuropathic pain, document prior consideration of standard neuropathic pain treatments and that IV anesthetic infusion is investigational for these indications.
No step therapy requirements described
No step therapy (mandatory prior trial of specific therapies) requirements are specified in the policy; the document discusses standard therapies but does not impose step therapy rules for IV anesthetic infusions.
- The policy describes conventional treatments (e.g., neuropathic agents) but does not define step therapy protocols to be followed prior to IV anesthetic infusion.
Documentation: record that an IV anesthetic infusion was performed and detail associated visits
Ensure medical record documentation clearly indicates that an IV anesthetic infusion was provided and include clinical rationale — however, note the policy designates these services as investigational for the listed indications.
- Document the agent administered, route (intravenous), dose, duration of infusion, and the clinical indication.
- Record any associated office/clinic visits, psychotherapy sessions, or evaluation and management encounters that occurred during administration.
Benefit verification required — consult member booklet or customer service
Consult the member benefit booklet or contact customer service to confirm whether IV anesthetic infusion services are covered for the specific member—coverage is subject to plan limits.
- Member contracts differ; confirmation is required to determine coverage for a specific medical service or supply.
Denial risk: IV ketamine or other IV anesthetic infusion claims may be denied as investigational
Be aware that claims for intravenous infusion of ketamine (including ketamine‑assisted psychotherapy) or other IV anesthetics (e.g., lidocaine) for the policy’s listed indications are considered investigational and may be denied.
- Investigational designation applies to treatment of depression, anxiety, other psychiatric disorders, substance use disorders, chronic pain (including neuropathic pain, chronic daily headache, fibromyalgia).
- Include clear documentation if submitting for payment, but expect potential denial due to investigational status.
Investigational designation of IV ketamine and associated visits triggers denial risk
Note that the policy explicitly designates IV ketamine in any setting and any associated visits or therapy sessions during which it is administered as investigational; these designations trigger noncoverage/denial for those services.
- The clarified policy states IV ketamine is investigational in any setting or in conjunction with any other service.
- Any office/clinic visits, psychotherapy sessions, evaluation and management sessions, or other sessions during which IV ketamine is administered are also considered investigational.
Background and Rationale
Intravenous subanesthetic infusions of agents such as ketamine or lidocaine have been investigated primarily as short courses—ranging from single infusions to series over days—with variable protocols (bolus followed by infusion, treatment durations from 1–6 hours up to multiple days). Studies have evaluated these approaches for chronic neuropathic pain, chronic daily headache, fibromyalgia, and treatment‑resistant psychiatric disorders (e.g., depression, OCD, PTSD). The literature shows some short‑term symptom improvement in select small trials but limited durability of benefit, potential for significant adverse events, and methodological limitations (small sample sizes, lack of active controls, and possible unblinding), which underpin the policy’s investigational designation.
Definitions
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