G387

PDF page 469 / J55

INTRAVENOUS
  + G376 Newborn or infant ................................................................... 10.20
  + G379 Child, adolescent or adult .......................................................     6.15
        Note:
        1.G376 or G379 apply to cryoprecipitate infusion.
        2.G376 or G379 may not be claimed with x-rays as they are included in the service.
        3.Except for G381, injections into established I.V. apparatus may not be claimed.
               G389 Preparation and infusion of gamma globulin, per patient, per
                      day......................................................................................           13.90
  + G380 Cutdown including cannulation as necessary.........................                                              27.05
    G387 Intravenous local anaesthetic infusion for central neuropathic
            pain.....................................................................................                   125.00
                                          Payment rules:
                                          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.
                                          Medical record requirements:
                                          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.

PDF page 469 / J55

[Commentary:
                                          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. ]

Master, record 2098. Record Layout PDF, page 1.

G38720250401999999990000125000000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.