Prior Authorization

Breast Reconstruction

67:16:02:05.10. Breast reconstruction. Breast reconstruction surgery is covered if the surgery is needed because of a medically necessary mastectomy.

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.
   

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Surgical Evaluation and applicable medical records

Submit completed documentation to:

• Department of Social Services
  Division of Medical Services
  Nurse Consultant
  700 Governors Drive
  Pierre, SD 57501
  
• Phone: 605-773-3495
  
• Fax: 605-773-5246