Prior Authorization Request Services and Forms

Lymphedema Pumps

67:16:29:02.05. Lymphedema pumps -- Limits. Coverage of lymphedema pumps is subject to the following restrictions:

1. The pump must be provided in the recipient's residence;
   
   
2. All other first-line treatments, such as salt restriction and wrapping, have failed; and
   
   
3. The provider must have received prior written authorization from the department as provided under § 67:16:29:02.06.
   
   

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.

Documentation Requirements for Prior Authorization Requests:

• General Prior Authorization Request Form
• Physician’s prescription
• Medical Records including:
  • Diagnosis
  • Previous treatments attempted and results
  Or documentation of why more conservative treatments have not been attempted
  • Aniticipated length of treatment
  • If a segmental pump is being prescribed, documentation must substantiate the contraindication of the non-segmental pump

Mail or fax your completed form and documentation to: