Prior Authorization Request Services and Forms
Written prior authorization will be required from the South Dakota Medical Assistance program. This procedure will not be covered for cosmetic purposes. In order for prior authorization to be granted the procedure must be considered medically necessary and the following criteria must be met:
- The recipient is 21 years or older;
- The pannus causes a continuous or frequently recurrent skin condition, such as intertrigo, cellulitis, or skin necrosis not responsive to documented good hygiene practices and conservative medical therapy of at least 6 months duration;
- The panniculus hangs below the symphysis with photographic documentation submitted;
- The pannus significantly interferes with activities of daily living; and
- If the surgery is considered after significant non-surgical weight loss there must be documentation of stable weight for 6 months or if the weight loss occurs after bariatric surgery panniculectomy will not be considered until at least 18 months after the bariatric procedure and documentation of stable weight for at least the last 6 months.
67:16:01:06.02. Covered services must be medically necessary. Services covered under this article must be medically necessary. To be medically necessary, the covered service must meet the following conditions:
- It is consistent with the recipient's symptoms, diagnosis, condition, or injury;
- It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider's peer group;
- It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;
- It is not furnished primarily for the convenience of the recipient or the provider; and
- There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.
Documentation Requirements for Prior Authorization Requests:
- Prior Authorization Request Form
- Surgical Evaluation
- Applicable medical records describing problems related to pannus and conservative treatments tried.
- Pictures of the pannus.
Mail or fax your completed form and documentation to:
- Division of Medical Services
700 Governors Drive
Pierre, SD 57501
- Phone: 605-773-3495
- Fax: 605-773-5246