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General weight loss plans and exercise programs are not covered under the Medical Assistance Program. However, when weight loss is essential to the treatment of health conditions, physicians may provide evaluation and management services to promote diet modification, increased physical activity, and behavior change. In addition, the Office of Medical Services will cover FDA approved weight-loss medications for individuals on a case by case basis. Please have the individual’s pharmacist contact the Division of Medical Services for prior authorization of these medications, if appropriate.
Body mass reduction procedures that are medically indicated as a priority health concern may be prior authorized, when conservative management has been exhausted. Cosmetic procedures are not a covered service under the program. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and perception of unacceptable appearance.
In order to review a request, the primary care medical documentation must substantiate symptomatology that is refractory to conservative management. If the individual has increasing symptoms a request for a surgical procedure may be reviewed. Only cases that have undergone the above medical management should be submitted.
Applicable Administrative Rules of South Dakota (ARSD)
67:16:01:01. Prior authorization," the written approval and issuance of an authorization by the department to a provider before certain covered services may be provided;
67:16:01:06.01. Covered services. Covered services are those medically necessary health care services or items that are within the service limits and meet the prior authorization requirements specified in this article. The department will pay for a medically necessary covered service furnished to a recipient or to a person who is found to be eligible on the date of service.
Prior authorization is based on a review of required documentation to determine if the conditions for Medicaid payment have been met. The review is not considered a medical consultation