Intravenous lidocaine (J2001) is approved systemically by the U.S. Food and Drug Administration (FDA) for the acute treatment of arrhythmias and locally as an anesthetic. Intravenous lidocaine for the treatment of chronic pain is an off-label use.

Ketamine hydrochloride (J3490) 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. Intravenous ketamine for the treatment of chronic pain is an off-label use.

Intravenous infusion of anesthetics (e.g., Ketamine or lidocaine) for the management of chronic neuropathic pain is considered experimental/investigational, and therefore, not covered. A participating, preferred, or network provider can bill the member for the non-covered service.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition.

Harbut RE, Correll GE. Successful treatment of a nine-year case of complex regional pain syndrome type-I (reflex sympathetic dystrophy) with intravenous ketamine-infusion therapy in a warfarin-anticoagulated adult female patient. Pain Med. 2002;3(2):147-55.

Correll GE, Maleki J, Gracely EJ, Muir JJ, Harbut RE. Subanesthetic ketamine infusion therapy: a retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med. 2004;5(3):263-75.

Kiefer RT, Rohr P, Ploppa A, Nohé B, Dieterich HJ, Grothusen J, Altemeyer KH, Unertl K, Schwartzman RJ. A pilot open-label study of the efficacy of subanesthetic isomeric S(+)-ketamine in refractory CRPS patients. Pain Med. 2008;9(1):44-54.

Kiefer TR, Rohr P, Ploppa A, Nohé B, Dieterich HJ, Grothusen J, Koffler S, Altemeyer KH, Unertl K, Schwartzman RJ. Efficacy of ketamine in anesthetic dosage for the treatment of refractory complex regional pain syndrome: an open-label phase II study. Pain Med. 2008;9(8):1173-201.

Schwartzman RJ, Alexander GM, Grothusen JR, Paylor T, Reichenberger E, Perreault M. Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: a double-blind placebo controlled study. Pain. 2009;147(1-3):107-15.

Sigtermans MJ, van Hilten JJ, Bauer MC, Arbous MS, Marinus J, Sarton EY, Dahan A. Ketamine produces effective and long-term pain relief in patients with complex regional pain syndrome type 1. Pain. 2009;145(3):304-11.

Nama S, Meenan DR, Fritz WT. The use of sub-anesthetic intravenous ketamine and adjuvant dexmedetomidine when treating acute pain from CRPS. Pain Physician. 2010;13(4):365-8.

Goldberg ME, Torjman MC, Schwartzman RJ, Mager DE, Wainer IW. Pharmacodynamic profiles of ketamine (R)- and (S)- with 5 day inpatient infusion for the treatment of complex regional pain syndrome. Pain Physician. 2010;13(4):379-87.

Blue Cross Blue Shield Association, Intravenous Anesthetics for the Treatment of Chronic Neuropathic Pain. Medical Policy Reference Manual 5.01.16. Issued August, 2010.