Print Intravenous Anesthetics for the Treatment of Chronic Pain

Intravenous Anesthetics for the Treatment of Chronic Pain

 

DESCRIPTION

Intravenous (IV) infusion of lidocaine or ketamine has been investigated for the treatment of migraine and chronic daily headache, fibromyalgia, and chronic neuropathic pain. Chronic neuropathic pain disorders include phantom limb pain, post-herpetic neuralgia, complex regional pain syndrome (CRPS), diabetic neuropathy, and pain related to stroke or spinal cord injuries. IV infusion of ketamine has also been investigated for the treatment of depression and obsessive compulsive disorder. For these applications, one or more courses of IV infusion would be administered over a period of several hours or several days.

Courses of IV anesthetic agents may be given in the inpatient or outpatient setting as part of a pain management program, with the infusion of a sub-anesthetic dose preceded by a bolus infusion to achieve desired blood levels sooner.

Ketamine is an antagonist of the N-methyl-D-aspartate (NMDA) receptor and a dissociative anesthetic. It is the sole anesthetic agent approved for diagnostic and surgical procedures that do not require skeletal muscle relaxation. Respiratory depression may occur with overdosage or too rapid a rate of administration of ketamine; it should be used by or under the direction of physicians experienced in administering general anesthetics. Ketamine is a schedule III controlled substance. Psychological manifestations vary in severity from pleasant dream-like states to hallucinations and delirium, and can be accompanied by confusion, excitement, aggression, or irrational behavior. The occurrence of adverse events with IV anesthetics may be reduced by the careful titration of sub-anesthetic doses. However, the potential benefits of pain control must be carefully weighed against the potential for serious, harmful adverse events.

Lidocaine, which prevents neural depolarization through effects on voltage-dependent sodium channels, is also used systemically for the treatment of arrhythmias. Adverse events for lidocaine are common, can be mild to moderate, and include general fatigue, somnolence, dizziness, headache, periorbital and extremity numbness and tingling, nausea, vomiting, tremors, and changes in blood pressure and pulse. Severe adverse effects may include arrythmias, seizures, loss of consciousness, confusion, or even death. Lidocaine should only be given intravenously to patients with normal conduction on electrocardiography and normal serum electrolyte concentrations to minimize the risk of cardiac arrythmias.

IV administration of anesthetic has been reported for various conditions, including chronic pain of neuropathic origin, chronic headache, fibromyalgia, depression, and obsessive compulsive disorders. Chronic daily headache is defined as a headache disorder that occurs more than 15 days a month for at least 3 months. Chronic daily headache includes chronic migraine, new daily persistent headache, hemicranias continua, and chronic tension-type headache.

Neuropathic pain is often disproportionate to the extent of the primary triggering injury and may consist of thermal or mechanical allodynia, dysesthesia, and/or hyperalgesia. Allodynia is when pain occurs from a stimulus that normally does not elicit a painful response (e.g., light touch, warmth). Dysesthesia is a constant or ongoing unpleasant or electrical sensation of pain. Hyperalgesia is an exaggerated response to normally painful stimuli. In the latter, symptoms may continue for a period of time that is longer (e.g., 6 months or more) than clinically expected after an illness or injury. It is proposed that chronic neuropathic pain results from peripheral afferent sensitization, neurogenic inflammation and sympathetic afferent coupling, along with sensitization and functional reorganization of the somatosensory, motor and autonomic circuits in the central nervous system (CNS). Therefore, treatments focus on reducing activity and desensitizing pain pathways, thought to be mediated through N-methyl-d-aspartate (NMDA) receptors, in the peripheral and central nervous system. Sympathetic ganglion blocks with lidocaine have been utilized for a number of years to treat sympathetically maintained chronic pain conditions, such as complex regional pain syndrome (previously known as reflex sympathetic dystrophy). Test infusion of an anesthetic has also been used in treatment planning to assess patient responsiveness to determine whether medications, such as oral mexiletine or oral ketamine may be effective. A course of IV lidocaine or ketamine, usually at sub-anesthetic doses, has also been examined. This approach for treating chronic neuropathic pain differs from continuous subcutaneous or IV infusion of anesthetics for the management of chronic pain conditions, such as terminal cancer pain, which are not discussed in this policy.

Fibromyalgia is a chronic state of widespread pain and tenderness. Although fibromyalgia is generally considered to be a disorder of central pain processing or central sensitization, others have proposed that the nerve stimuli causing pain originates mainly in the muscle, causing both widespread pain and pain on movement. There are focal areas of hyperalgesia, or tender points, which tend to occur at muscle tendon junctions. Biochemical changes that have been associated with fibromyalgia include alterations in NMDA receptors, low levels of serotonin, suppression of dopamine-releasing neurons in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis, and elevated substance P levels. Fibromyalgia is typically treated with neuropathic pain medications such as pregabalin, non-narcotic pain relievers, or low doses of antidepressants.

Use of IV ketamine has also been reported for treatment-resistant depression, defined as depression that does not respond adequately to appropriate courses of antidepressant medications. Particularly challenging are patients with treatment-resistant depression with suicidal ideation. Several studies are ongoing to test the efficacy of IV ketamine in patients with suicidal ideation who present to the emergency department.

Intravenous (IV) lidocaine is approved by the U.S. Food and Drug Administration (FDA) for systemic use in the acute treatment of arrhythmias and locally as an anesthetic. IV lidocaine for the treatment of chronic pain is an off-label use.

Ketamine hydrochloride injection is FDA-indicated for diagnostic and surgical procedures that do not require skeletal muscle relaxation, for the induction of anesthesia prior to the administration of other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide. IV ketamine for the treatment of chronic pain is an off-label use.

 

POLICY

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.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

IV lidocaine is approved systemically by the U.S. Food and Drug Administration (FDA) for the treatment of antiarrythmias and locally as an anesthetic. IV lidocaine for the treatment of chronic pain is an off-label use.

Ketamine hydrochloride injection is FDA-indicated for diagnostic and surgical procedures that do not require skeletal muscle relaxation, for the induction of anesthesia prior to the administration of other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide. IV ketamine for the treatment of chronic pain is an off-label use.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized  as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

7/15/2004: Approved by Medical Policy Advisory Committee (MPAC)

10/1/2004: Code Reference section completed

5/10/2006: Policy reviewed, no changes

6/18/2007: Policy reviewed, description updated. Ketamine added to policy as investigational. "Lidocaine" replaced with "Anesthetics" in policy title. Added CPT 90765, 90766, 90774, and 90775 to code reference section

7/19/2007: Reviewed and approved by MPAC

12/19/2007: Coding update per 2008 CPT/HCPCS revisions

7/11/2008: Policy reviewed, no changes

12/31/2008: Code Reference section updated per 2009 CPT/HCPCS

10/13/2009: Description section updated. Policy title changed-"Management" updated with "Treatment and "neuropathic" added.

09/09/2010:  Policy reviewed; no changes to description or policy statement.  Removed deleted CPT codes 90765, 90766, 90774, 90775, and 90776 from the Code Reference section.

11/10/2011:  Policy description updated regarding intravenous lidocaine and ketamine hydrochloride injection. "Neuropathic" deleted from the policy title. Added fibromyalgia to the policy statement.

01/09/2013:  Policy reviewed; no changes.

11/15/2013:  Policy reviewed; no changes.

02/02/2015: Policy reviewed; description updated regarding chronic daily headache. Investigational policy statement updated to change "management" to "treatment" and to add chronic daily headache.

08/27/2015: Code Reference section updated to add ICD-10 codes.

11/17/2015: Policy description updated regarding fibromyalgia and the use of IV ketamine. Policy statement unchanged. Investigative definition updated in policy guidelines section.

 

SOURCE(S)

Blue Cross Blue Shield Association policy # 5.01.16

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

Code Number

Description

CPT-4

96365

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); 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

96375

Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

96376

Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)

HCPCS

J2001

Injection, lidocaine HCl for intravenous infusion, 10 mg

ICD-9 Procedure

ICD-10 Procedure

99.29

Injection or infusion of other therapeutic or prophylactic substance

3E033FZ

Introduction of Intracirculatory Anesthetic into Peripheral Vein, Percutaneous Approach

ICD-9 Diagnosis

ICD-10 Diagnosis

  

 

 

 

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