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Clinical Policy Title: Ketamine (Ketalar®) for the treatment of Complex Regional
Pain Syndrome (CRPS)
Clinical Policy Number: (391) 00.02.01
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
June 1, 2013
March 21, 2013
April 23, 2013
May 2014
Policy contains:
• CRPS
• Ketamine
• Intravenous Regional Sympathetic
Nerve Blockade (IVRB)
Lines of Business: Select Health clinical policies are subject to all applicable laws and government
regulatory requirements of the geographical areas served. Refer to the pertinent government and
plan documents for each geographical area for guidance. Individual member benefits must be
verified.
Policy Definition: Select Health covers health care service/items when they are medically
necessary and not prohibited from coverage by state or federal laws and/or regulatory
requirements. This Select Health clinical policy addresses the medical evidence supporting the use
of Ketamine (Ketalar®) for the treatment of Complex Regional Pain Syndrome (CRPS).
Select Health considers the use of Ketamine (Ketalar®) for the treatment of Complex Regional Pain
Syndrome (CRPS) to be investigational as the effectiveness of its use has not been established in
peer reviewed professional literature. These clinical policies, along with other sources, such as
plan benefits and state and federal laws and regulatory requirements, including any State or plan
specific definition of medically necessary, are considered by Select Health when making coverage
determinations.
Coverage Policy: Select Health considers all uses of ketamine (Ketalar®) for the treatment of
complex regional pain syndrome (CRPS) to be not medically necessary, and therefore, not covered,
as the effectiveness of its use has not been established in peer reviewed professional literature.
Limitations: The use of Ketamine for CRPS.
Alternative Covered Services:
• Oral Pharmacotherapy with analgesics, antidepressants and anticonvulsants, antiinflammatory, corticosteroids, and bone loss medications.
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•
•
•
Desensitization of peripheral nerve receptors.
Nerve root stimulation, e.g. TENs.
Physical therapy
Background:
Therapeutic pain management is often difficult to accomplish, and certain diseases present more
challenges than others to both clinicians and individual patients. Complex regional pain syndrome
(CRPS) is one of these challenging disease entities. As signified in its title, pain is the preeminent
component of CRPS. The syndrome is part of a classification of neuropathic pain disorders, and
these are related to pathology in the peripheral and central nervous system. There is no cure for
CRPS, and the chronic nature of the disease, combined with the expectancy that the pain will
worsen over time, adds to the burden of effective pain management.
The International Association for the Study of Pain (IASP) considers CRPS to be a syndrome that
usually develops after an initiating noxious event, and is not limited to the distribution of a single
peripheral nerve. The pain is regional in location, with neither a specific nerve territory nor
dermatome. Usually, it displays a distal predominance of abnormal sensory, motor sudomotor,
vasomotor edema, and, or other trophic manifestation. The pain is also characterized by either a
continuing evoked or, spontaneous occurrence that is disproportionate to the initiating event. This
disproportion may be either in the time, or the degree of pain, related to the usual course of
recuperation after the noxious event.
CRPS pain is also associated with the presence of edema, changes in skin circulation, allodynia, or
hyperalgesia, and abnormal sudomotor activity. CRPS symptoms include pain that is usually
accompanied by a sensation of burning, and worsens in intensity. The pain usually affects the
extremities and may spread from the site of the injury to affect the entire limb. CRPS pain may
also spread to the corresponding limb on the opposite of the body.
Currently, there are two recognized types of CRPS, these are:
• Type 1: Previously known as reflex sympathetic dystrophy syndrome (RSD), it occurs most
often after an illness or injury that did not directly damage the nerves in the affected limb.
It may develop after any type of trauma, especially a fracture. The majority of people with
CRPS have type 1.
• Type 2: Once referred to as causalgia, type 2 follows any identified injury to a nerve.
Other possible causes of CRPS suggested by professional literature include, but are not limited to,
non- surgical procedures, drug exposure, stroke with hemiplegia, and cervical spondylosis. The
causative mechanism as to why an injury may trigger CRPS is not completely understood. CRPS
research during the past decade indicates multifactorial causes with both peripheral and central
nervous system involvement. These mechanisms may include inflammation, altered sympathetic
and catecholaminergic function, altered somatosensory representation in the brain, genetic
factors, and psychophysiologic interactions (Bruehl, 2010). CRPS may develop as a result of an
inappropriate response, or dysfunctional link between transmissions in the peripheral and central
nervous system. Research suggests that a reduction in small-diameter nerve fibers is evident in
CRPS type 1, and that the spontaneous pain develops when a portion of the nervous system that
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normally conducts pain signals becomes electrically overactive (Oaklander, et al., 2006). The pain
may be attributed to the activation of pain receptors (nociceptors) that transduce and encode
noxious stimuli (Dworkin, et al., 2003). Other research suggests that an individual’s pain system
develops a capacity for increased sensitivity after injury, a nociceptor sensitization, which may lead
to the development of persistent pain (Cheng & Ji, 2008).
Diagnosis of CRPS
There is no uniformly accepted list of diagnostic criteria or a single test that can definitively
diagnose CRPS. This disease occurs in both genders, and individuals of all ages, though literature
suggests that CRPS may be more common between the ages of 40 to 60 years of age. The onset of
CRPS symptoms usually occur within one month of the noxious event. (Harden, 2001).
Clinical findings are the gold standard for the diagnosis of CRPS, and these are based on individual
physical examination and medical history. The physical and medical history may include these
findings:
• A damaging, painful event to a limb, or not moving a limb for a long period of time
• The presence of pain that is not proportionate to any stimulus, such as pain with light
touch.
• A history of swelling, changes in temperature, or skin blood flow in the affected limb.
• The absence of any other cause for the above listed symptoms.
Studies have been conducted for the validity of skin surface temperature recordings in the
diagnosis of CRPS. These studies were based on calculated methods using thermographic data to
diagnose acute CRPS1 in fracture patients (Niehof, et al., 2008). Study data suggested that the
most pronounced differences among subgroups involved vasomotor signs in the CRPS I group. The
result illustrated the limited use of skin surface temperature to discriminate between CRPS I
patients. The use of the following procedures may provide important information to assist in a
diagnosis of CRPS; however their use may still yield an incomplete clinical picture and borderline
diagnosis. Imaging methods are not able to differentiate between CRPS 1 and the results of posttraumatic changes. These procedures have a low sensitivity, and a low predictive value, suggesting
their worth only as adjunct tools to establish a diagnosis in dubious cases (Schürmann, et al.,
2007).
• Bone scan. This procedure is designed to detect changes in the bone. A radioactive
substance is injected into the veins; the substance permits the viewing of the bones with a
special camera.
• Sympathetic nervous system tests. These tests are used to detect changes in the
sympathetic nervous system on the affected limbs; differences in results between limbs
may indicate CRPS.
• X-rays. An x-ray may detect the loss of mineral content from the bone, a symptom seen in
the later stages of CRPS.
• Magnetic resonance imaging (MRI): The images from this test may show changes within
the affected tissues.
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Treatment for CRPS
Therapeutic approaches to CRPS are not uniform, and in some cases controversial. Some of the
difficulty lies in the incomplete knowledge surrounding the causative factors for CRPS types 1 & 2.
This lack of knowledge has slowed the progress of research for effective CRPS treatments. General
consensus in professional literature supports early diagnosis with aggressive treatment for CRPS.
Ideally, early treatment will stem the scale and scope of the symptoms, with a possible
containment of the progression of the syndrome (Schwartzman, 2000). Improvement and even
remission of complex regional pain syndrome is possible if treatment begins within a few months
of the first symptoms. Individuals presenting with severe pain are less likely to have successful
pain amelioration or resolution than those presenting with moderate pain. Rehabilitation may be
extended due to a delay in the initiation of treatment. Permanent tissue damage, impairment,
and living with chronic pain may occur without therapeutic intervention (Atkin, 2003).
Treatment of CRPS should be immediately after it is diagnosis and directed towards the recovery
of function in the affected extremity or body region. Often, a combination of various therapies is
necessary. Treatment should be comprehensive, multidisciplinary, emphasize functional
restoration and pain management, and be specifically tailored to the individual case. Proposed
treatment options may include the following:
• Physical & Occupational Therapy
• Pain relievers: Over-the-counter (OTC) pain relievers, such as aspirin, ibuprofen, and
naproxen, may ease pain and inflammation. For pain not relieved by OTC products, opioid
medications may be an option. Taken in appropriate doses, these may provide acceptable
pain control.
• Antidepressants and anticonvulsants: These medications may be used to treat pain that
originates from a damaged nerve (neuropathic pain).
• Corticosteroids. Steroid medications may reduce inflammation and improve mobility in the
affected limb.
• Bone-loss medications.
• Desensitization of peripheral nerves receptors with nerve root stimulation.
• Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in
the affected nerve(s) may provide pain relief.
Other treatment methods to address CRPS may include the use of sympathetic nerve blocks and
surgical procedures. Currently, the role of surgery to treat CRPS is limited. Sympathetic nerve
blocks with a variety of medications have been used for CRPS pain. Research within the last
decade revealed the scarcity of published evidence to support the use of local anesthetic
sympathetic blockade as the 'gold standard' treatment for CRPS, and no conclusions concerning
the effectiveness of this procedure could be drawn. There is a need to conduct randomized
controlled trials to address the value of sympathetic blockade with local anesthetic for the
treatment of CRPS (Cepeda, 2005). Spinal cord stimulation may also be effective for reducing pain
in approximately two thirds of CRPS patients not responding to other treatments, but its efficacy
appears to diminish over time. (Henson P, Bruehl, S., 2010)
The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic
refractory pain has increased since its inception in the 1980s. The advent of new algorithmic tracks
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for neuropathic and nociceptive pain is an important step in improving patient care, and the need
for clinical research in IT therapy is ongoing. Specific brands of infusion systems have been FDA
approved for use in IT. However, the use of IT analgesics in not generally recommended (AHRQ,
2012). Recent conclusions from an interdisciplinary expert panel encourage continued research
and development, including the development of new drugs, devices, and safety recommendations
to improve the care of patients with chronic pain (Deer, et al. 2012).
Intravenous Regional Sympathetic Nerve Blockade (IVRB) has also been proposed as a treatment
for CRPS. These procedures are designed to introduce a concentration of medication into a finite
area at the sympathetic nerve endings in a particular region of the body. The intent is to produce
a sympathetic denervation without disrupting motor activity. The substances used in IVRB have
not been wholly supported for use in CRPS. Professional literature suggests that ethical reasons
should allow individuals to undergo a well-defined trial of a finite number of nerve blocks if
attempts at functional restoration have been unsuccessful (Harden 2001).
The Use of Ketamine for CRPS
Ketamine hydrochloride for injection (Ketalar®) is a well-known, rapid acting anesthetic drug that
was granted New Drug Application (NDA) approval more than 40 years ago (February 19, 1970). It
has both antinociceptive and antihyperalgesic effects that are primarily based on the antagonism
of the N-Methyl-D-aspartate (NMDA) receptor. Central NMDA receptors activated by excitatory
amino acid glutamate are involved in pain processing, neuronal plasticity, and central sensitization.
The rationale to use ketamine for the treatment of CRPS is based on this ability to block NMDA
receptors. As an NMDA antagonist, it has been purported to reduce continuous and evoked pain
when given in prolonged and low doses to individuals with injuries of both the peripheral and
central nervous system. Thus, ketamine has been used off-label, administered topically or
intravenously in small, sub anesthetic doses as an analgesic for treating painful conditions
(Hocking & Cousins, 2003). Extended use of ketamine at anesthetic dosages ("ketamine coma")
remains a controversial and unproven treatment for CRPS.
Sigtermans et al conducted a double-blind, randomized placebo-controlled trial with 60
participants with severe pain. Each participant received either ketamine or saline infused over 4
days at an inpatient facility. The ketamine was titrated at regular intervals to a maximum dosage
of 30mg per hour for a seventy kilogram patient. Infusion rates were increased when pain relief
was deemed insufficient. Blood pressures were monitored, and liver function studies were
conducted daily. Pain scores over the 12-week monitoring period were significantly lower than
those in patients receiving placebo (P < 0.001); however, the significance was not present between
the groups at week 12 (P = 0.07). Patients receiving the drug experienced more psychomimetic
side effects than controls (93% vs. 17%, P < 0.001). Ketamine treatment did not cause functional
improvement in either group. The authors suggest that 4-day treatment with low-dose ketamine is
safe, with psychomimetic side effects that were acceptable to most patients.
Another double-blind, randomized placebo-controlled trial with 21 participants diagnosed with
refractory CRPS was conducted by Schwartsman, et al. Nine participants were placed in the
ketamine group and 10 were in the placebo group. All participants were subjected to daily four
hour infusions with either ketamine or normal saline according to their respective group for ten
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days (5 days on, 2 days off, 5 days on). The maximum ketamine rate was 0.35 mg/kg/hour, not to
exceed 25 mg/our over a four hour period; this was a subanesthetic dose of ketamine. All
participants were monitored at two weeks, and then monthly for a period of three months. After
treatment the ketamine group showed a 21.4% reduction in pain to 6.01 ± 0.6 P< 0.01), with both
a sensory and affective component demonstrated of a decrease in pain that lasted for the three
month follow-up period. The placebo group demonstrated a non-significant 3.1% reduction to
6.98 ± 0.5 (P> 0.05), with no demonstrable treatment effects. There was no change in participant
activity in either the pre- or, post-treatment phase. Side effects were described as nausea,
headache, tiredness, or dysphoria in 4 out of 9 patients in the ketamine group and in 2 out of 10
patients in the placebo group. The authors also note two points in relation to the addition of
midazolam and clonidine with the dose of ketamine: 1) the apparent lack of psychomimetic side
effects, and 2) that in their experience only a 5 day course of intravenous ketamine at anesthetic
doses with midazolam and clonidine would provide complete, lasting remission of CRPS symptoms
for over 5 years. The trial was terminated prematurely as the researchers found that ketamine at
doses of 50 mg/hour provided a much larger relief from pain that lasted for a longer period of time
with the absence of complications. However, the authors note the necessity for larger,
randomized, placebo-controlled trials using higher doses of ketamine, with lengthier follow-up
periods.
Although the rationale for using ketamine seems appropriate, studies to date have not yet
validated its benefit using objective outcome parameters with double-blind, randomized control
(RCT) methodology.
Questions of safety remain regarding the use of repeat infusion of ketamine for the return of CRPS
pain. Additionally, multiple researchers have not been able to determine optimal treat regimes for
the use of Ketamine in CRPS (Sunder, 2008; Bell & Moore, 2010; Azari 2012). A summary of the
main issues are as the follows:
• The optimal duration and dosing of ketamine infusions.
• The effectiveness of the setting for the infusions; inpatient versus outpatient.
• Using ketamine on its own, or, as an adjunct to regional anesthetic blocks.
• Ketamine usage in diagnosed refractory cases of CRPS.
• The use of ketamine prior to an established diagnosis of CRPS.
Glossary of terms:
Allodynia – The perception of pain due to a stimulus that does not usually cause pain, e.g.
clothing.
Chronic pain – Pain lasting for longer than three months, or beyond the time of expected healing.
Central sensitization – The increased excitability of nociceptive neurons in the spinal cord,
triggered from constant or extremely noxious input related to tissue or nerve damage.
Hyperalgesia – Increased sensitivity, and/or pain from a noxious stimulus that usually causes pain.
Nociceptor – A sensory receptor, for pain, that is capable of converting and transferring noxious
stimuli.
Noxious stimulus – Any stimulus that may damage body tissues.
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Related Policies: Select Health Utilization Management Program Description
REFERENCES
Professional Society Guidelines
Agency for Healthcare Quality (AHRQ). United States Department of Health and Human Services.
Complex regional pain syndrome/reflex sympathetic dystrophy medical treatment guidelines.
Updated December 28, 2012. [AHRQ Website]. Available
at: http://guidelines.gov/content.aspx?id=38440. Accessed February 28, 2013.
Perez RS, Zollinger PE, Dijkstra PU, et al. CRPS I task force. Evidence based guidelines for complex
regional pain syndrome type 1. BMC Neurol. March 2010. 31; 10:20. [BMC Website]. Available
at: http://www.biomedcentral.com/1471-2377/10/20 . Accessed February 2 8, 2013.
The International Association for the Study of Pain (IASP). Classification of chronic pain. Original
1986. Revised 2011. [IASP Web site.] Available at:
http://www.iasppain.org/Content/NavigationMenu/Publications/FreeBooks/Classification_of_Chronic_Pain/defaul
t.htm
Accessed February 28, 2013.
Evidence Based References
Alexander GM, Peterlin BL, Perreault MJ, Grothusen JR, Schwartzman RJ. Changes in plasma
cytokines and their soluble receptors in complex regional pain syndrome. J Pain. 2012 Jan;
13(1):10-20.
Azari P, Lindsay DR, Briones D., et al. Efficacy and safety of ketamine in patients with complex
regional pain syndrome: a systematic review. CNS Drugs. 2012 Mar 1; 26(3):215-28.
Backonja M, Arndt G, Gombar KA, Check B, Zimmermann M. Response of chronic neuropathic pain
syndromes to ketamine: a preliminary study. Pain. Jan 1994; 56(1):51-7.
Bruehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiology.
2010 Sep; 113(3):713-25. Available
at: http://www.rsds.org/pdfsall/Bruehl_Anesthesiology_2010.pdf
Accessed February 28, 2013.
Cepeda MS, Carr DB, Lau J. Local anesthetic sympathetic blockade for complex regional pain
syndrome. Cochrane Database Syst Rev. 2005; 19:CD004598.
Cheng, J., Ji, RR. Intracellular signaling in primary sensory neurons and persistent pain. Neurochem
Res. 2008. October, 33(10):1970-1978
Deer TR, Prager J, Levy R, et al. Polyanalgesic Consensus Conference 2012: recommendations for
the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary
expert panel. Neuromodulation. 2012 Sep-Oct; 15(5):436-64; discussion 464-6. Epub 2012 Jul 2.
FC-HC_2014_85 | Clinical Guideline 00.02.01 Ketamine (Ketalar) for the treatment of Complex Regional Pain Syndrom (CRPS)
Page 7 of 10
Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in Neuropathic Pain: Diagnosis,
Mechanisms, and Treatment Recommendations. Arch Neurol. 2003; 60:1524-1534.
Goldberg M, Torjman M, Schwartzman R, et al. Pharmacodynamic profiles of ketamine (R-) and
(S+) with five day inpatient infusion for the treatment of complex regional pain syndrome. Pain
Physician. July 2010; 13(4); 379-387.
Harden RN. Complex regional pain syndrome. Br J Anaesth. 2001;87:99-106.
Harden RN, Bruehl SP. Diagnosis of complex regional pain syndrome: signs, symptoms, and new
empirically derived diagnostic criteria. Clinical Journal of Pain. 2006; 22:415-419
Harden R., Bruehl, S., Perez, R., et al. Validation of proposed diagnostic criteria (the "Budapest
Criteria") for Complex Regional Pain Syndrome. Pain. 2010 Aug; 150(2):268-74. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914601/pdf/nihms222091.pdf. Accessed
February 28, 2013.
Hayes, Inc. Health Technology Brief. Intravenous Ketamine for chronic nonmalignant pain.
Lansdale, PA. [Hayes, Inc. Website]. Login required. March 2011. Accessed February 28, 2013.
Henson P, Bruehl S. Complex regional pain syndrome: state of the art update. Curr. Treat Options
Cardiovase Med. 2010: 12(2):156-67.
Hocking G, Cousins MJ. Ketamine in chronic pain management: an evidence-based review. Anesth
Analg. 2003 Dec; 97(6):1730-9.
Jadad A., Carroll, D., Glynn D., McQuay, H. Centre for Reviews and Dissemination (CRD). Abstract
and Commentary for: Intravenous Regional sympathetic blockade for pain relief in reflex
sympathetic dystrophy: a systematic review and a randomized, double-blind crossover study.
National Health Service, University of York: York, U.K. 3:2003b.
Ji RR., Woolf C., Neuronal plasticity and signal transduction in nociceptive neurons: Implications for
the initiation and maintenance of pathological pain. Neurobiology of Disease, Volume 8, Issue 1,
February 2001, Pages 1-10
Kiefer RT, Rohr P, Ploppa A, et al. Efficacy of ketamine in anesthetic dosage for the treatment of
refractory complex regional pain syndrome: an open-label phase II study. Pain Med. 2008; 9:11731201.
Harden RN. Complex regional pain syndrome. Br J Anaesth. 2001; 87:99-106.
Kiefer RT, Rohr P, Ploppa A, et al. A pilot open-label study of the efficacy of subanesthetic
isomeric S(+)-ketamine in refractory CRPS patients. Pain Med. 2008 Jan-Feb; 9(1):44-54.
National Institute of Neurological Disorders and Stroke (NINDS). Updated September 28, 2012.
[NINDS website]. Complex Regional Pain Syndrome Fact Sheet. Available at:
http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/detail_reflex_sympathetic_dy
strophy.htm . Updated September 19, 2012. Accessed February 2 8, 2013.
FC-HC_2014_85 | Clinical Guideline 00.02.01 Ketamine (Ketalar) for the treatment of Complex Regional Pain Syndrom (CRPS)
Page 8 of 10
Niehof SP, Beerthuizen A, Huygen FJ, Zijlstra FJ. Using skin surface temperature to differentiate
between complex regional pain syndrome type 1 patients after a fracture and control patients
with various complaints after a fracture. Anesth Analg. 2008; 106(1):270-277. International
Anesthesia & Analgesia Society. [Anesthesia & Analgesia Web site.] Available
at: http://www.anesthesia-analgesia.org/content/106/1/270.full.pdf+html
Oaklander A., Rissmiller J., Gelman L., et al. Evidence of focal small-fiber axonal degeneration in
complex regional pain syndrome-I (reflex sympathetic dystrophy). Pain, February 2006, Vol. 120,
pp. 235-243.
Perez RS, Kwakkel G, Zuurmond WW, de Lange JJ. Treatment of reflex sympathetic dystrophy (CRPS type 1):
a research synthesis of 21 randomized clinical trials. J Pain Symptom Manage. Jun 2001; 21(6):511-26.
Perez RS, Zollinger PE, Dijkstra PU, et al. CRPS I task force. Evidence based guidelines for complex
regional pain syndrome type 1. BMC Neurol. March 2010. 31; 10:20.
Rowbotham MC. Pharmacologic management of complex regional pain syndrome Clin J Pain. 2006
Jun; 22(5):425-9.
Schürmann M, Zaspel J, Löhr P, et al. imaging in early posttraumatic complex regional pain
syndrome: A comparison of diagnostic methods. Clin J Pain. 2007; 23(5):449-457.
Schwartzman R., New treatments for reflex sympathetic distrophy. New England Journal of
Medicine. 2000; 343:654-656.
Schwartzman R., Alexander G., Grothusen J., et al. Outpatient intravenous ketamine for the
treatment of complex regional pain syndrome: A double-blind placebo controlled study. Pain.
2009; 147:107-115.
Schwartzman, R., Alexander, G., Grothusen, J. The use of ketamine in in Complex regional pain
syndrome: possible mechanisms. Expert Rev. Neurother. 11(5), 719-734 (2011).
Sigtermans, M., van Hilten, J., Bauer, M. Ketamine produces effective and long-term pain relief in
patients with Complex regional pain Syndrome Type 1. International Association for the Study of
Pain (IASP). Pain. June 18, 2009.
Stanton-Hicks M, Baron R, Boas R, et al. Consensus report: complex regional pain syndromes:
guidelines for therapy. Clin J Pain. 1998; 14:155-166.
Sunder RA, Toshniwal G, Dureja G. Ketamine as an adjuvant in sympathetic blocks for
management of central sensitization following peripheral nerve injury. J Brachial Plex Peripher
Nerve Inj. Oct 25 2008; 3:22.
Clinical Trials
Double Blind Placebo Controlled Study of Outpatient Intravenous Ketamine for the Treatment of
CRPS. Completed June 2010. R. Schwartzman.
Centers for Medicare Services (CMS) National Coverage Determination
FC-HC_2014_85 | Clinical Guideline 00.02.01 Ketamine (Ketalar) for the treatment of Complex Regional Pain Syndrom (CRPS)
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As of the writing of this policy, there was no CMS coverage determination addressing
percutaneous therapy with ketamine, or intravenous regional sympathetic nerve block (IVRB) or,
systemic IV administration, for complex regional pain syndrome (CRPS).
Local Care Determinations
As of the writing of this policy, there was no Local Care Determinations (LCDs) addressing
percutaneous therapy with ketamine, or intravenous regional sympathetic nerve block (IVRB) or,
systemic IV administration, for complex regional pain syndrome (CRPS)
Commonly Submitted Codes:
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy.
This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding
manuals and bill in accordance with those manuals.
CPT Code
Description
Comment
Description
Comment
N/A
ICD-9 Code
337.20
337.21
337.22
337.29
354.4
355.71
733.7
Reflex sympathetic dystrophy, unspecified
Reflex sympathetic dystrophy of the upper limb
Reflex sympathetic dystrophy of the lower limb
Reflex sympathetic dystrophy of other specified site
Causalgia of upper limb
Causalgia of lower limb
Algoneurodystrophy
HCPCS
Level II
J3490
Description
Comment
Ketamine, IV
Disclaimer: Select Health has developed clinical policies to assist with making coverage determinations.
Select Health clinical policies are based on guidelines from established industry sources such as Centers for
Medicare and Medicaid (CMS), State regulatory agencies, the American Medical Association (AMA), medical
specialty professional societies, and peer reviewed professional literature. These clinical policies, along
with other sources, such as plan benefits and state and federal laws and regulatory requirements, are
considered by Select Health when making coverage determinations. Select Health clinical policies are for
informational purposes only and not intended as medical advice or to direct treatment. Physicians and
other health care providers are solely responsible for the treatment decisions for their patients. Select
Health clinical policies are reflective of evidence based medicine at the time of review. As medical science
evolves, Select Health will update its clinical policies as necessary. Select Health clinical policies are not
guarantees of payment.
5-22-2013
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