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 used for the treatment of chronic neuropathic pain. Chronic neuropathic pain disorders include phantom limb pain, post-herpetic neuralgia, complex regional pain syndromes, diabetic neuropathy, and pain related to stroke or spinal cord injuries. For this application, one or more courses of IV infusion would be administered over a period of several hours or several days. 

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 when there is a constant or ongoing unpleasant or electrical sensation of pain. Hyperalgesia is when there is an exaggerated response to normally painful stimuli. 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. 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 (CRPS, 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.

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

Ketamine is an antagonist of the 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 side effects 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 side effects.

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 management of chronic   pain, including, but not limited to chronic neuropathic pain 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 service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

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.

 

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

96365Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (List separately in addition to code for primary procedure) 
96366Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 
96374Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 
96375Therapeutic, 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)   
96376Therapeutic, 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) 

ICD-9 Procedure

99.29 Injection or infusion of other therapeutic or prophylactic substance

ICD-9 Diagnosis

  

HCPCS

J2001 Injection, lidocaine HCl for intravenous infusion, 10 mg

 

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