Prior Authorization Request Services and Forms

Hyperbaric Oxygen Therapy

The 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.

To be medically necessary, the covered service must meet the following conditions (ARSD 67:16:01:06.02):

67:16:02:05.08. Requirements for hyperbaric oxygen therapy. Hyperbaric oxygen therapy is a modality in which the entire body is placed in a chamber and exposed to oxygen under increased atmospheric pressure. The department must authorize hyperbaric oxygen therapy before it is provided. Hyperbaric oxygen therapy is limited to outpatient treatment for treatment of the following:

1. Acute carbon monoxide intoxication;
   
   
2. Decompression illness;
   
   
3. Gas embolism;
   
   
4. Gas gangrene;
   
   
5. Acute traumatic peripheral ischemia. Adjunctive treatment must be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened;
   
   
6. Crush injuries and suturing of severed limbs. Adjunctive treatment must be used when loss of function, limb, or life is threatened;
   
   
7. Meleney ulcers. Any other type of cutaneous ulcer is not covered;
   
   
8. Acute peripheral arterial insufficiency;
   
   
9. Preparation and preservation of compromised skin grafts;
   
   
10. Chronic refractory osteomyelitis which is unresponsive to conventional medical and surgical management;
    
    
11. Osteroradionecrosis as an adjunct to conventional treatment;
    
    
12. Soft tissue radionecrosis as an adjunct to conventional treatment;
    
    
13. Cyanide poisoning;
    
    
14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment; or
    
    
15. Diabetic wounds of the lower extremities if the requirements of § 67:16:02:05.13 are met.
    
    

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Medical record documentation to meet the above requirements

Mail or fax your completed form and documentation to:

DSS, Division of Medical Services
Nurse Consultant
811 E. 10th Street Dept. 8
Sioux Falls, SD 57103-1650
Phone: (605) 367-7601
Fax: (605) 367-5253