Provider Information

Prior Authorization Request Services and Forms

Body Mass Reduction Procedures

Documentation Requirements

The primary care medical record must contain the following information:

Current actual height and weight;
Clinical evaluation of the signs or symptoms have been present for at least 6 months;
Non-surgical interventions as appropriate;
Therapies prior to reduction mammaplasty and the response to this treatment;
Determining the symptoms are refractory to appropriately fitted supporting garments;
Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management;
Reduction of obesity status via weight management.

The plastic surgeon’s medical documentation must include:

Current actual height and weight;
Legible and thorough examination of findings;
Estimated amount of tissue to be removed;
Multiple views to demonstrate macromastia;
Other options for treatment in addition to surgical management.

Applicable Administrative Rules of South Dakota (ARSD)

ARSD 67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:

1. It is consistent with the recipient's symptoms, diagnosis, condition, or injury;
2. It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;
3. It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;
4. It is not furnished primarily for the convenience of the recipient or the provider; and
5. There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.

67:16:02:05.02. Breast reductions covered -- Prior authorization required. The department must prior authorize surgery to reduce the size of the breast. The authorization is based on documentation submitted to the department by the physician. The documentation must substantiate the existence of the following conditions:

1. The breasts extend down to at least the level of the antecubital fossae (elbow);
2. The weight of the breasts causes frequent backache;
3. Supporting bra straps cut into the skin of the shoulders causing tissue breakdown;
4. The size of the breasts causes significant interference with activities of daily living;
5. If the individual is obese, evidence that weight reduction has not reduced the symptoms described in this section.