Provider Information
Prior Authorization Request Services and Forms
Durable Medical Equipment (DME)
The Certificate of Medical Necessity for Durable Medical Equipment (DME) is to be completed by the prescribing physician for all types of covered durable equipment ordered for Medical Assistance Program eligible recipients. This form is to be used by DME suppliers as written documentation to support medical necessity and must be completed and maintained in the patient’s medical record prior to submitting a claim to the South Dakota Medical Assistance Program.
Durable Medical Equipment Services that Require Prior Authorization
- Lymphedema Pumps (Compressors and Accessories)
- non-segmental pumps
- segmental pumps
- Pressure Reduction Therapy
- pressure reduction overlay or mattress
- low air-loss bed therapy
- air-fluidized therapy
- Augmentative Communication Devices & Accessories
- rental
- purchase
- modification
- repairs exceeding $500
- Chest Compression Generation System
- Cough Stimulating Devices
- Passive Motion Devices
- Negative Pressure Wound Therapy
Certificate of Medical Necessity for Durable Medical Equipment
Nicki Bartel, RN, RHIT
Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone: (605) 773-3495
Fax: (605) 773-5246
