Prior Authorization

Continuous Glucose Monitoring Policy

South Dakota Medical Assistance program will not cover continuous glucose monitoring systems for individual recipients.

With Prior Authorization, South Dakota Medical Assistance program may provide continuous glucose monitoring under the following circumstances:

1. If continuous glucose monitoring is provided by the recipient’s endocrinologist, South Dakota Medical Assistance program will reimburse the cost of monitoring for a continuous 72 hour period 2 times per year through the endocrinologist’s office;  
   
2. If a recipient already owns the continuous glucose monitoring system, the South Dakota Medical Assistance program will provide coverage for one box of 4 sensors every 6 months.

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• All applicable medical records to support requirements in ARSD.
  • These must include the appropriate x-ray reports and interpretations.

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