Prior Authorization

Breast Reduction

The South Dakota Medical Assistance program must prior authorize surgery to reduce the size of the breast.  The authorization is based on documentation submitted to the South Dakota Medical Assistance program by the physician performing the procedure. 

The documentation must substantiate the existence of the following conditions:

• The individual must be at least 21 years of age and have reached physical maturity.
• If the individual has a BMI of more than 35 there must be documentation of  participation in a physician supervised weight loss program over 6 months without any change in the size of the breasts.
• If the individual is age 40 or older must have had a normal mammogram within the last 2 years, or if age 35 to 40 and has a first degree relative with breast cancer must have had one normal mammogram.
• The individual has not given birth in the last 6 months.
• The individual suffers from severe back or neck pain resulting in interference with activities of daily living and not responsive to documented conservative treatment after 3 months; or the individual suffers from nerve root compression symptoms of ulnar pain or paresthesias not responsive to documented conservative treatment after 3 months.
• The individual has intertrigo not responsive to documented medical treatment after 3 months.
• The amount of tissue to be removed in grams must be equal or greater to the criteria in the chart below (calculated by the Gehan/George formula).

The surgeon must submit photographic documentation confirming severe macromastia. A complete history and physical, including height and weight must be submitted with the prior authorization request. An estimate of amount of tissue (in grams) to be removed from each breast should be submitted with the request for prior authorization and a copy of the operative report with documentation of tissue removed must be submitted with the claim form. 

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.

Documentation Requirements:

• Prior Authorization Request Form
• Sugical Consultation and applicable medical records.

Documentation must include the following:

• 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;
  
• Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management;
  
• Legible and thorough examination of findings;
  
• Estimated amount of tissue to be removed;
  
• Pictures with multiple views
  
• Other options for treatment in addition to surgical management.
  measurement of ptosis

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