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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.
Lidocaine, which prevents neural depolarization through effects on voltage-dependent sodium channels, is also used systemically for the treatment of arrhythmias. Lidocaine should only be given intravenously to individuals with normal conduction on electrocardiography and normal serum electrolyte concentrations to minimize the risk of cardiac arrhythmias. IV lidocaine is approved by the U.S. Food and Drug Administration 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 is an antagonist of the N-methyl-_-aspartate 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. The potential benefits of pain control must be carefully weighed against the potential for serious, harmful adverse events. 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 is an off-label use.
Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Intravenous infusion of anesthetics (e.g., ketamine hydrochloride, or lidocaine) for the management of chronic pain, chronic neuropathic pain, chronic daily headache, and fibromyalgia is considered experimental/investigational, and therefore, not covered. Scientific evidence does not support the use of intravenous infusion of anesthetics for chronic pain.
Procedure Codes
Intravenous infusion of anesthetics (e.g., ketamine hydrochloride) for the management of psychiatric disorders is considered experimental/investigational, and therefore, not covered. Scientific evidence does not support the use of intravenous infusion of anesthetics (e.g., ketamine hydrochloride) for psychiatric disorders.
Procedure Code
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.
Diagnosis Codes
Non-Covered Diagnosis Codes for Procedure Codes J2001 and J3490 (ketamine hydrochloride)
G89.21
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G89.22
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G89.28
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G89.29
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G89.4
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G90.50
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G90.511
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G90.512
|
G90.513
|
G90.519
|
G90.521
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G90.522
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G90.523
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G90.529
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G90.59
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M79.7
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|
|
|
|
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Non-Covered Diagnosis Codes for Procedure Code J3490 (ketamine hydrochloride)
F33.0
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F33.1
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F33.2
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F33.3
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F33.40
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F33.41
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F33.42
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F33.8
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F33.9
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|
Professional Statements and Societal Positions Guidelines
Not Applicable
ND Committee Review
Internal Medical Policy Committee 9-21-2020 Adopted policy
Internal Medical Policy Committee 9-21-2021 Annual Review
Internal Medical Policy Committee 5-24-2022
- Added dx code M79.7 to the policy
Internal Medical Policy Committee 5-23-2023 Annual review, no clinical content change
Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024
- Annual review no clinical content change
Internal Medical Policy Committee 9-17-2024 Effective October 01, 2024
Links
References
