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Thread: Gralise Effectiveness for SCI Neuro pain? Help with Medicare approval.

  1. #1
    Junior Member
    Join Date
    May 2011
    Woodstock, GA

    Gralise Effectiveness for SCI Neuro pain? Help with Medicare approval.

    Hi Y'all,
    I have two questions: One about Gralise, a time-released version of Gabapentin/Neurontin and the other about strategies for getting approval if I want to fight Medicare on their denial of it. Please see my "background" info below the post regarding my SCI, pain, yadda yadda yadda...

    I'm currently seeing a new pain management doc who has given me a starter pack of Gralise, a time-released version of Gabapentin (Neurontin). Has anyone else with SCI long-term chronic nerve pain found this helpful? I'm into my 3rd week- still dealing with some side effects, but have noticed that it seems to be generally helpful. My problem is that Humana/Medicare's Clinical Review team has rejected this drug as it is only approved for Diabetic Neuropathy & Post-Herpatic Pain. They also said that the diagnosis of Lumbo-Sacral Neuritis is not covered as a "medically accepted indication for this diagnosis". Because this is a new doc, I haven't had my records sent over yet, but I do think she can provide a better diagnosis or ICD 9 code, like Central Pain or Peripheral Neuropathy. Any suggestions would be greatly appreciated!

    Long timer SCI (32 years and counting) with chronic neuropathic pain. I'm a 50 year old T12/L1 Para and have dealt with this pain with various degrees of success over the years. I've done tons of research on NeuroPhysiology & Neuro pain: the different types of Neuropathic pain, the neurotransmitters GABA, and the invariable issues with gene expression of Glial cells, the pathological positive feedback loop these Glial cells create. It has always been very specific: Shooting, electrical, pins & needles in my right butt cheek, and skin-level on the top of my right thigh.

    Over the years, I've tried pretty much all the standard anti-seizure meds and had limited relief, but usually ended up needing dosage levels that made me feel like a zombie- the dosages that helped with the pain had so many other side effects it made their use intolerable. Currently, I'm taking 15 mg Oxycodone, along with Effexor 150mg. For me, opioids have really been the most effective meds in terms of dosages vs side effects vs functionality. That's why I really liked the intrathecal morphine pump- it seemed to knock out 80% of my pain, but I could function, and didn't feel- under the influence of anything. My goal is to limit the amount of opioids so that I can take them when my pain is really bad, and still get relief from it.

    Have had 2 Medtronic intrathecal pumps (1st was put in early 90's great relief for 10+ years with Morphine, 2nd was 3 years ago-implanted above injury level- tried Prialt- that was a nightmare), Bos Sci SC Stimulator (terrible- 2 surgical implants- it never could reach my very specific pain area). The 1st pain pump allowed me to work in my profession, travel around the world and overall, have an awesome, fully active and integrated life, until the dosage amounts got higher and I found myself sleeping on weekends in order to make it through the week.

  2. #2
    Give your current doctor your old medical records indicating that you've had prior intolerable side effects or an inadequate therapeutic response to TWO lower tier formulary medications ( one of which needs to be Gabapentin ). Can't help you with the diagnostic code. Gralise is expensive and has narrow indications in most managed care formularies.

  3. #3
    couldnt they put in a stronger med in your pain pump? like fentyl
    cauda equina

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