Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

POLICY NUMBER

A.5.01.16

DESCRIPTION

Intravenous (IV) infusion of lidocaine or ketamine has been investigated for the treatment ofmigraine and chronic daily headache, fibromyalgia, and chronic neuropathic pain. Chronic neuropathic pain disorders include phantom limb pain, post-herpetic neuralgia, complex regional pain syndrome, diabetic neuropathy, and pain related to stroke or spinal cord injuries. An IV infusion of ketamine has also been investigated for treatment-resistant depression and obsessive-compulsive disorder.

Intravenous Anesthetic Agents

Courses of intravenous (IV) anesthetic agents may be given in the inpatient or outpatient setting as part of a pain management program, with the infusion of a subanesthetic dose preceded by a bolus infusion to achieve desired blood levels sooner. Treatment protocols for the initial cycle may include infusion of subanesthetic doses for one to six hours for up to ten days.

LidocaineLidocaine, 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 events 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 arrhythmias.

KetamineKetamine is an antagonist of the N-methyl-D-aspartate receptor and a dissociative anesthetic. Respiratory depression may occur with overdosage or a rapid rate of ketamine administration. Ketamine is a schedule III controlled substance. Psychological manifestations vary in severity from pleasant, dream-like states to hallucinations and delirium; further, these manifestations 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 must be carefully weighed against the potential for serious, harmful adverse events.

IndicationsThe IV administration of anesthetics has been reported for various conditions, including chronic headache, chronic pain of neuropathic origin, fibromyalgia, depression, and obsessive compulsive disorders.

Chronic daily headache is defined as a headache disorder that occurs 15 or more days a month for more than 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 pain that 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 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 receptors in the peripheral and central nervous system. Sympathetic ganglion blocks with lidocaine have been used 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 subanesthetic doses, has also been examined. This approach for treating chronic neuropathic pain differs from continuous subcutaneous or IV infusion of anesthetics for managing chronic pain conditions, such as terminal cancer pain, which is not discussed in this policy.

Fibromyalgia is a chronic state of widespread pain and tenderness. Although fibromyalgia is generally considered 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 associated with fibromyalgia include alterations in N-methyl-D-aspartate 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.

The 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 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 or psychiatric disorders is considered an off-label use.

Ketamine hydrochloride injection is approved for diagnostic and surgical procedures that do not require skeletal muscle relaxation, for the induction of anesthesia before 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 or psychiatric disorders is an off-label use.

POLICY

Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for thetreatment of chronic pain, including, but not limited to chronic neuropathic pain, chronic daily headache, and fibromyalgia, is considered investigational.

Intravenous infusion of anesthetics (eg, ketamine or lidocaine) for the treatment of psychiatric disorders, including but not limited to treatment-resistant depression, obsessive-compulsive disorder, and post-traumatic stress disorder is considered investigational.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

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.

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.

05/26/2016: Policy number A.5.01.16 added.

01/09/2018: Policy description updated. Policy statement unchanged.

01/09/2019: Policy reviewed. Added psychiatric disorders to investigational policy statement.

01/13/2020: Policy title changed from "Intravenous Anesthetics for the Treatment of Chronic Pain" to "Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders." Policy description updated regarding intravenous anesthetic agents. Policy section updated to add a separate investigational statement regarding intravenous infusion of anesthetics for the treatment of psychiatric disorders. The policy statement previously stated: 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, fibromyalgia, and psychiatric disorders, is considered investigational.

06/16/2020: Code Reference section updated to add HCPCS code J7999.

01/15/2021: Policy description updated. Policy statements unchanged.

02/01/2022: Policy reviewed; no changes.

01/20/2023: Policy description updated. Policy statements unchanged.

01/04/2024: Policy description updated. Policy statements unchanged.

10/01/2024: Code Reference section updated to make note of deleted HCPCS code.

02/04/2025: Policy reviewed. Policy statement regarding psychiatric disorders updated to change "depression" to "treatment-resistant depression" and to add post-traumatic stress disorder to the list of conditions.

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

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