Medical Services

Provider Information

Prior Authorization Request Services and Forms

Obesity and Gastric Procedures

Gastric procedures for weight loss are not a covered service under the Administrative Rules of South Dakota (ARSD) that govern the Medical Assistance Program [67:16:01:08(13)].

However, when weight loss is critical to the treatment of severe co-morbid conditions, cases may be reviewed for medical necessity (ARSD 67:16:01:06.02). A prior authorization process is available for severe cases utilizing South Dakota specialist evaluations. This determination may take six months or longer. Individuals with Medicare primary must seek a coverage determination from Medicare.

In order to obtain prior authorization the following information may be requested:

  • Medical history to establish the intractable treatment of morbid obesity
  • Current psychological/psychiatric evaluation
  • Specialist evaluations that document the severity of a co-morbid condition such as cardiac disease, respiratory disease, hypertension, or diabetes
  • Surgical evaluation

The following guidelines will be used to identify candidates that will meet medical necessity criteria ARSD 67:16:01:06.02 (1-3).

Consulting specialists, such as endocrinologists may be utilized to establish ARSD 67:16:01:06.02 (4-5) if a candidate presents borderline clinical data.

  • The individual is severely obese with Body Mass Index (BMI) over 40. BMI - weight in kilograms (2.2 lbs/kg ) divided by the square of height in meters (39.37 in/meter).
  • There is a significant interference with activities of daily living.
  • There is documented failure of any sustained weight loss under medical supervision.
  • It is medically appropriate for the individual to have such surgery.
  • The surgery has been prior authorized by the department.
  • There is medical documentation of one of the following:
    1. History of pain and limitation of motion in any weight-bearing joint or the lumbosacral spine (as documented by physical examination in association with radiologic findings); or
    2. Hypertension with diastolic blood pressure persistently in excess of 100 mm Hg measured with appropriate size cuff; or
    3. Congestive heart failure manifested by past evidence of vascular congestion such as hepatomegaly, peripheral or pulmonary edema; or
    4. Chronic venous insufficiency with superficial varicosities in a lower extremity with pain on weight bearing and persistent edema; or
    5. Respiratory insufficiency or hypoxemia at rest.

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.

General Prior Authorization Request Form

The General Prior Authorization Request Form is to be completed by the prescribing physician for all covered services requiring prior authorization for Medical Assistance Program eligible recipients.

This form is to be used by providers 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.

Division of Medical Services
700 Governors Drive
Pierre, SD 57501
Phone: (605) 773-3495
Fax: (605) 773-5246

Provider Resource Links

Childhood Obesity:

National Institutes of Health Obesity Resources:

United States Department of Health & Human Services - Healthier US.GOV:

United States Preventive Services Task Force: