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Prior Authorization

Prior Authorization Request Services and Forms

Implanted Nerve Stimulators

The implantation of a central nervous system stimulator may be covered by the South Dakota Medical Assistance program as therapy for relief of chronic non-malignant intractable pain (greater than 6 month’s duration) when the following criteria are met:

  1. There is documentation in the medical record of failure of 6 months of conservative therapy (pharmacologic, surgical, psychological, physical), if appropriate and not contraindicated;
  2. Further surgical intervention is not indicated;
  3. A psychological evaluation has been obtained and there is documentation that the pain is not psychological in origin;
  4. No contraindications to implantation exist; and
  5. A temporary trial of spinal cord stimulation has shown 50% reduction in pain for at least 2 days and there is documented improvement in function.

Sacral Nerve Stimulation

With written authorization from the South Dakota Medical Assistance program implantable Sacral Nerve Stimulators may be approved for the treatment of urinary voiding dysfunction (urinary urge incontinence, non-obstructive urinary retention, and urinary urgency/frequency syndrome) when the following conditions are met:

  1. Patient has not responded to prior behavioral and pharmacological interventions over 6 months of documented treatment;
  2. Incontinence is not related to a neurological condition;
  3. Symptoms of incontinence have been present for at least 12 months and have resulted in significant disability, such as limited ability to work or participate in activities outside the home; and
  4. A test stimulation has demonstrated 50% or greater improvement in incontinence, as documented in voiding diaries submitted for review with the request.

Documentation Requirements for Prior Authorization Requests:

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