Prior Authorization Request Services and Forms
High-Frequency Chest Wall Oscillation Devices
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:
- It is consistent with the recipient's symptoms, diagnosis, condition, or injury;
- It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;
- 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;
- It is not furnished primarily for the convenience of the recipient or the provider; and
- 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.
Documentation Requirements for Prior Authorization Requests:
- General Prior Authorization Request Form
- Medical records including:
- physician’s prescription
- any previous hospitalizations for respiratory illness
- Documentation of failure of standard treatments to adequately mobilize retained secretions.
- or documentation supporting why other more conservative treatments have not been attempted.
Mail or fax your completed form and documentation to:
Division of Medical Services
700 Governors Drive
Pierre, SD 57501