1. G387 is only insured for patients with central neuropathic pain who have first undertaken but not responded to generally accepted medical therapy.
2. The physician submitting the claim for this service must remain in constant attendance during the infusion and no part of the procedure may be delegated or G387 is not payable.
3. G387 is limited to a maximum of 6 per patient per 12 month period.
The medical record for the service must document the prior medical therapy that the patient did not respond to or G387 is not eligible for payment.
1. Central neuropathic pain is pain caused by a primary lesion or dysfunction that affects the central nervous system.
2. At the time of this amendment to the Schedule of Benefits, generally accepted medical therapy that would be required prior to G387 is treatment with both a tricyclic antidepressant and at least one anticonvulsant.
3. For Intravenous drug test for pain, see Z811 p. X1.