CurrentPremera BluecrossPolicy 5.01.586

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders

Defines coverage position for intravenous infusion of anesthetics (e.g., ketamine, lidocaine) when used to treat chronic pain syndromes (including neuropathic pain, chronic daily headache, fibromyalgia) and psychiatric disorders (including depression, anxiety, OCD, PTSD, and substance use disorders). Also lists applicable CPT/HCPCS codes and summarizes evidence and guidance.

Policy Summary

PayerPremera Bluecross

PolicyIntravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders

Policy CodePolicy 5.01.586

Change TypeAnnual literature reviewcoding update

Effective Date

Next Review Date

Key ActionClaims for IV infusion of anesthetics (e.g., ketamine, lidocaine) for chronic pain or psychiatric/substance use disorders are considered investigational and not covered; providers should document indication but expect denial if submitted for these indications.

SourceLink

POLICY UPDATE CHANGES

Policy updated with literature review through October 1, 2025; policy statements unchanged.

Initial policy replaced prior policy 5.01.16 and expanded to include IV ketamine for psychiatric symptoms and disorders in earlier history.

3Investigational indications listed

6CPT/HCPCS codes referenced

100+Clinical trials on ketamine (ClinicalTrials.gov)

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Overview: Policy 5.01.586 defines the coverage position for intravenous anesthetics (e.g., ketamine, lidocaine) when used to treat chronic pain syndromes (including neuropathic pain, chronic daily headache, fibromyalgia) and psychiatric disorders (including depression, anxiety, OCD, PTSD, and substance use disorders). Status: CURRENT; Last review: 2026-05-01 (annual review approved April 27, 2026). Scope: applies to inpatient and outpatient IV infusion protocols (subanesthetic dosing, bolus followed by infusion) investigated for these indications. Key coverage position: IV anesthetics (ketamine, lidocaine) for chronic pain and for psychiatric or substance use disorders are considered investigational and are not covered for these indications.

Surface quick facts

Policy Number5.01.586

StatusCURRENT

Last Review2026-05-01

ScopeIntravenous anesthetics (ketamine, lidocaine) for chronic pain and psychiatric or substance use disorders

Medical Necessity / Investigational Determinations

Investigational / Not Medically Necessary

Intravenous infusion of anesthetics is considered investigational (unproven) for the following uses:

ALL of the following

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.
Intravenous infusion of ketamine for the treatment of depression, anxiety, or other psychiatric symptoms or disorders, including substance use disorders.
Intravenous infusion of ketamine in conjunction with psychotherapy (ketamine-assisted therapy) for the treatment of depression, anxiety, or other psychiatric symptoms or disorders, including substance use disorders.

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Evidence synthesis: For chronic pain, randomized trials and reviews have not shown durable benefit (insufficient evidence); small ketamine trials suggest only limited, short-term relief. For treatment-resistant depression, trials show short-term improvement in some studies but limited durability and concerns about controls/blinding. For other psychiatric disorders (OCD, PTSD and similar), results are mixed and overall evidence is insufficient to demonstrate net health outcome improvement.

Coding

CPT codes referencedCPT

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 ... second physician or other qualified health care professional, concurrent with first ... each hour (List separately in addition to code for primary procedure).
0822T	Continuous in-person monitoring and intervention ... clinical staff under the direction of a physician or other qualified health care professional, concurrent ... each hour.
96365	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour.
96366	Each additional hour (list separately in addition to code for primary procedure).
96374	Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance/drug.

HCPCS / J-codes referencedHCPCS

J3490

Unclassified drugs.

Removed HCPCS code (history)HCPCS

J2001

Removed from policy; termed October 1, 2024.

Provider Actions & Billing Impact

Documentation Required

Do not cover investigational uses

Claims for IV infusion of anesthetics (for example, ketamine or lidocaine) when submitted for chronic pain (including chronic neuropathic pain, chronic daily headache, fibromyalgia) or for psychiatric or substance use disorders (including depression, anxiety, OCD, PTSD, and substance use disorders) are considered investigational and are not covered. Providers should document the indication on claims but should expect denials when these services are billed for these indications.

0820T
0821T
0822T
96365
96366
96374
J3490

Provider guidance: If providers submit claims for IV ketamine or lidocaine for these investigational indications, they should document the specific indication in the claim; however, these uses are considered investigational and are not covered, and denials should be expected. The CPT and HCPCS codes listed in the policy (e.g., 0820T–0822T, 96365, 96366, 96374, J3490) may be used on claims but are not covered when billed for these investigational indications.

Background & Evidence Summary

Background: Intravenous lidocaine and ketamine have been investigated off-label for migraine and chronic daily headache, fibromyalgia, chronic neuropathic pain (including phantom limb pain, post-herpetic neuralgia, CRPS, diabetic neuropathy), and for treatment-resistant psychiatric disorders such as major depression and OCD. Typical protocols involve a series of IV infusions (subanesthetic doses with possible bolus) over days. Safety and durability concerns have been raised: adverse events can be serious (arrhythmias, seizures, dissociation, hallucinations, respiratory depression) and clinical trials have generally shown limited treatment durability.

Evidence items

Durable benefit for chronic painInsufficient — RCTs failed to show durable effect for lidocaine; limited temporary relief (2-4 weeks) in small ketamine trials.

Treatment-resistant depression evidenceShort-term improvement in some trials; limited durability and concerns about controls/blinding; insufficient evidence for net health outcome improvement.

Other psychiatric disorders (OCD, PTSD)Mixed RCT results and small case series; insufficient evidence for net health outcome improvement.

Definitions / Glossary: • Chronic daily headache: headache occurring ≥15 days/month for ≥3 months (includes chronic migraine, new daily persistent headache, hemicrania continua, chronic tension-type headache). • Neuropathic pain: pain disproportionate to the triggering injury that may include allodynia, dysesthesia, or hyperalgesia and may persist ≥6 months after illness or injury. • Treatment-resistant depression: depression that does not respond adequately to appropriate courses of antidepressant medications.

Determination	Details
No national coverage determination	type: NCD; number: ; effective:

Revision History

04/27/2026annual reviewLatest

Annual review approved April 27, 2026. Policy updated with literature review through October 1, 2025; policy statements unchanged. Removed HCPCS code J2001 from policy (J2001 termed October 1, 2024).

08/01/2018policy creation / replacement

Initial policy approved July 10, 2018 and posted 08/01/18; this policy replaced prior policy 5.01.16 and the coverage criteria were amended to include IV ketamine for psychiatric symptoms and disorders.