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Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders
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This policy governs coverage of intravenous anesthetic infusions (e.g., ketamine, lidocaine) when used to treat chronic pain conditions or psychiatric/substance use disorders for Premera Bluecross members and notifies providers about investigational determination and coding guidance.
Modified criteria to clarify that 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.
Clarified that 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 effective October 1, 2024.
Coverage Criteria
Investigational (not covered) services
Covered when ALL of the following are met:
From Policy Coverage Criteria.
From Policy Coverage Criteria.
From Policy Coverage Criteria.
Policy coverage logic and evidence synthesis
Summary of evidence and policy stance informs coverage:
This investigational determination also applies to any associated office visits, clinic visits, psychotherapy sessions, evaluation and management sessions, or any other sessions during which IV ketamine is administered.
Intense treatment protocols, severity of adverse events, and short treatment durability limit clinical utility.
From Regulatory Status section.
The policy designates the intravenous infusion of ketamine for treatment of depression, anxiety, other psychiatric symptoms or disorders, substance use disorders, and/or chronic pain as investigational (not covered). This investigational determination applies in any setting and in conjunction with any other service, and explicitly includes ketamine-assisted psychotherapy. The policy also states that any associated office visits, clinic visits, psychotherapy sessions, evaluation and management sessions, or any other sessions during which IV ketamine is administered are considered investigational.
IV ketamine is considered investigational in any setting and when delivered with or without other services; this includes administration during psychotherapy, clinic or office visits, or evaluation-and-management encounters. The policy history clarifies that this change expands the investigational determination to apply broadly to IV ketamine regardless of treatment context and that associated visits or sessions during which IV ketamine is given are also treated as investigational.
For chronic pain indications, the policy concludes that IV anesthetic infusions (including ketamine and lidocaine) are investigational because randomized trials and observational studies have not demonstrated a durable benefit. Trials of IV lidocaine for postherpetic neuralgia, complex regional pain syndrome, and diabetic neuropathy failed to show lasting effects, and randomized trials of IV ketamine provide only limited, short-term relief in select studies. Concerns about intense treatment protocols, adverse events, and limited treatment durability lead to the determination that evidence is insufficient to establish a net health benefit.
Regarding psychiatric disorders, randomized controlled trials and case series report temporary or limited benefit of IV ketamine for some conditions (for example, small trials in OCD and PTSD), but the evidence is constrained by small sample sizes, potential publication bias, unblinding/carryover issues, short durability of response, and frequent adverse effects (e.g., headache, anxiety, dissociation, nausea, dizziness). Because of these limitations, the policy finds the evidence insufficient to demonstrate an improvement in net health outcome, and IV ketamine for these psychiatric indications is considered investigational.
Coding
| 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 | HCPCS code J2001 was removed from the policy (termed October 1, 2024). |
Provider Actions and Billing Guidance
Prior authorization noted but investigational services remain not payable
Intravenous infusion services and associated monitoring/psychotherapy encounter codes are listed in the coding section but the policy states these services are investigational for the covered indications; prior authorization will not make an investigational service payable.
Recent coding updates affecting authorization
The policy history documents that CPT codes 0820T–0822T were added and that HCPCS code J2001 was removed (termed effective October 1, 2024); providers should use the current listed CPT/HCPCS codes when submitting authorizations or claims.
Document conventional treatment options before investigational infusions
Conventional therapies for chronic neuropathic pain and fibromyalgia (e.g., pregabalin, non‑narcotic analgesics, low‑dose antidepressants) and techniques such as sympathetic ganglion blocks with lidocaine or test infusions to assess responsiveness are described as typical therapeutic context before investigational approaches.
- Sympathetic ganglion blocks with lidocaine have been used to treat sympathetically maintained chronic pain conditions (e.g., CRPS).
- Test infusion of an anesthetic has been used in treatment planning to assess individual responsiveness to oral mexiletine or oral ketamine.
Use guideline evidence to inform stepwise ordering decisions
Ordering should align with guideline context: the 2018 joint consensus guideline notes weak to moderate evidence for IV ketamine in select pain conditions (e.g., moderate evidence for CRPS up to 12 weeks) and generally weak or no evidence for many other pain conditions.
- Guideline findings include moderate evidence for CRPS (improvement up to 12 weeks) and weak or no evidence for mixed neuropathic pain, fibromyalgia, headache, and spinal pain.
- Use guideline context to inform stepwise local treatment decisions; it does not change the policy investigational determination.
Coding documentation guidance — use listed CPT/HCPCS codes
Code and documentation must reflect the specific infusion and monitoring services billed (use the CPT/HCPCS codes listed in the coding section for infusion, monitoring, IV push, and unclassified drugs).
Document off‑label use and clinical rationale for IV lidocaine or ketamine
IV lidocaine and IV ketamine for chronic pain or psychiatric disorders are off‑label uses; documentation should state the indication, rationale for off‑label use, and supporting clinical justification.
- Regulatory status: IV lidocaine is FDA‑approved for arrhythmias and local anesthesia; IV ketamine is FDA‑approved for anesthesia/diagnostic procedures—use for chronic pain or psychiatric disorders is off‑label.
- Include indication and rationale when documenting off‑label IV lidocaine or ketamine use in the medical record and any authorization requests.
Investigational services may be denied
Intravenous infusion of ketamine (including ketamine‑assisted psychotherapy and any associated visits/sessions) and intravenous infusion of other anesthetics (e.g., lidocaine) for the listed indications are designated investigational and therefore are subject to denial.
- This investigational determination applies in any setting or in conjunction with any other service.
- Associated encounters (office visits, psychotherapy sessions, E&M) during which IV ketamine is administered are also considered investigational.
Associated visits/sessions billed with IV ketamine may be denied
Claims for IV ketamine and any associated office/clinic/psychotherapy/E&M sessions during which IV ketamine is administered are considered investigational and therefore may be denied; billing for related visits may not be payable when the underlying infusion is investigational.
- The July 2026 modification clarified that investigational status applies to IV ketamine in any setting and to any associated visits or sessions during which IV ketamine is given.
- Submitters should expect possible denial of both infusion and concurrent visit/session claims when IV ketamine is the service performed for the investigational indications.
Background
IV ketamine and IV lidocaine have been studied as courses of infusions—often using subanesthetic bolus doses followed by infusions lasting approximately 1–6 hours and administered over multiple days in some protocols—for chronic neuropathic pain, fibromyalgia, chronic headache, and treatment‑resistant depression or other psychiatric disorders. Published randomized trials and systematic reviews report some short‑term symptom improvement in certain settings, but overall treatment durability is limited and adverse events are common, raising questions about long‑term safety and net clinical benefit.
Definitions
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