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Date Printed: October 23, 2017: 02:09 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-J0000-65

Original Effective Date: 09/15/04

Reviewed: 05/08/13

Revised: 11/01/15

Subject: Intravenous Lidocaine for the Management of Chronic Pain

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    

DESCRIPTION:

Intravenous (IV) lidocaine infusion can be used for the treatment of chronic pain from fibromyalgia and neuropathic pain disorders including phantom limb pain, post-herpetic neuralgia, complex regional pain syndromes, diabetic neuropathy, and pain related to stroke or spinal cord injuries. Chronic pain may consist of thermal or mechanical allodynia, dysesthesia, and/or hyperalgesia that continue for a period of time, such as over 6 months, or longer than clinically expected after an illness or injury.

IV lidocaine infusions are given in the inpatient or outpatient setting and may be part of a pain management program. Adverse effects are common and 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 include arrhythmias, seizures, and loss of consciousness, confusion or even death.

IV lidocaine should only be given to individuals with normal conduction on electrocardiography and normal serum electrolyte concentrations to minimize the risk of cardiac arrhythmias. During infusion, individuals should be kept under close observation for adverse effects and have continuous electrocardiographic monitoring and measurements of pulse and blood pressure. IV lidocaine may be preceded by a lidocaine bolus to achieve desired blood levels sooner.

POSITION STATEMENT:

Intravenous lidocaine for the management of chronic pain is considered experimental or investigational, as there is insufficient clinical evidence to support the use of intravenous lidocaine for the management of chronic pain. The available evidence in peer-reviewed publications on the use of IV lidocaine for chronic pain is lacking. Further studies are needed to determine appropriate patient selection criteria, predictive values, effective dosage ranges, frequencies, and duration of treatment.

BILLING/CODING INFORMATION:

HCPCS Coding:

J2001

Injection, lidocaine HCL for intravenous infusion, 10 mg

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline revised date: External infusion pumps, (L11555) located at fcso.com.

Medicare Part D: BCBSF has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline.

DEFINITIONS:

Allodynia: pain occurring from a stimulus that normally does not elicit a painful response (e.g., light touch, warmth).

Dysesthesia: a constant or ongoing unpleasant or electrical sensation of pain.

Hyperalgesia: an exaggerated response to normally painful stimuli.

RELATED GUIDELINES:

None applicable.

OTHER:

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

The American Academy of Neurology guideline for the treatment of migraine headaches indicates: “Recommendations: Evidence is insufficient to support the role for lidocaine IV in the management of acute migraine.”

REFERENCES:

  1. Clinical Pharmacology. Copyright® 2011 Elsevier. Accessed 01/18/13.
  2. Attal N, Rouaud J, Brasseur L, Chauvin M, Bouhassira D. Systemic lidocaine in pain due to peripheral nerve injury and predictors of response. Neurology. 2004 Jan 27; 62(2): 218-25.
  3. Carroll I, Gaeta R, Mackey S. Multivariate analysis of chronic pain patients undergoing lidocaine infusions: increasing pain severity and advancing age predict likelihood of clinically meaningful analgesia. Clin J Pain. 2007 Oct;23(8): 702-6.
  4. Challapalli V, Tremont-Lukats IW, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003345. DOI: 10.1002/14651858.CD003345.pub2.
  5. Challapalli V, Tremont-Lukats IW, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003345. DOI: 10.1002/14651858.CD003345.pub2.
  6. DRUGDEX®. Accessed 01/18/13.
  7. ECRI Intravenous Lidocaine for Chronic Pain. Custom Hotline Response. Updated 11/18/05.
  8. Facts & Comparisons® E Answers. Accessed 01/18/12.
  9. Finnerup NB, Biering-Sorensen F, Johannesen IL, Terkelsen AJ, Juhl GI, Kristensen AD, Sindrup SH, Bach FW, Jensen TS. Intravenous lidocaine relieves spinal cord injury pain: a randomized controlled trial. Anesthesiology. 2005 May; 102(5): 1023-30.
  10. Ingenex, HCPCS Level II Coding, 2011 Expert.
  11. Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Aker P, Cervical Overview Group. Medicinal and Injection therapies for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD000319. DOI: 10.1002/14651858.CD000319. Pub 3.
  12. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 Sep 26; 55(6): 754-62.
  13. Tremont-Lukats IV, Hutson PR, Backonja MM. A randomized, double-masked, placebo-controlled pilot trial of extended IV lidocaine infusion for relief of ongoing neuropathic pain. Clin J Pain. 2006 Mar-Apr; 22(3): 266-71.
  14. Wu CL, Tella P, Staats PS et al. Analgesic effects of intravenous lidocaine and morphine on postamputation pain: a randomized double-blind, active placebo-controlled, crossover trial. Anesthesiology 2002; 96(4): 841-8.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 05/08/13.

GUIDELINE UPDATE INFORMATION:

09/15/04

New Medical Coverage Guideline. Investigational.

09/15/05

Scheduled review and revision; consisting of updated references.

07/01/06

Updated MCG number from 02-61000-34 to 09-J0000-65.

09/15/06

Scheduled review and revision consisting of updated references.

07/15/07

Annual review, investigational status maintained, reformatted guideline, references updated.

08/15/07

Review and revision; consisting of reformatting guideline, maintaining current coverage and limitations, and updated references.

09/15/08

Reviewed guideline with no changes made. Updated references.

01/01/09

Annual HCPCS coding update: deleted 90765, 90766, and 90774; added 96365, 96366 and 96374.

09/15/09

Review and revision; consisting of updating references.

03/15/10

Review and revision; consisting of updating references.

03/15/11

Review and revision; consisting of updating references.

03/15/12

Review and revision to guideline; consisting of updating references.

06/15/13

Review and revision to guideline; consisting of updating program exceptions. No longer review.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 23, 2017: 02:09 AM