67:16:29:02.05. Lymphedema pumps -- Limits. Coverage of lymphedema pumps is subject to the following restrictions:
67:16:29:02.06. Lymphedema pumps -- Prior authorization -- Required documentation. Before the department authorizes a lymphedema pump, the provider must provide documentation to the department which substantiates the medical necessity of the pump. Medical documentation must include the diagnosis, the first line medical treatment attempted, and the anticipated length of treatment.
If the segmental pump is being required, documentation must substantiate the medical contraindication for the nonsegmental pump.
Mail or fax your completed form and documentation to:
Division of Medical Services
700 Governors Drive
Pierre, SD 57501