Prior Authorization Request Services and Forms

Low Air Loss / Pressure Reduction Therapy

67:16:29:02.01. Pressure reduction therapy -- Limits. Coverage for pressure reduction overlay or mattress, low-air-loss bed therapy, and air-fluidized therapy is subject to the following restrictions:

1. The services must be provided in the recipient's place of residence;
   
   
2. Services are limited to three months when prescribed by a physician for the active healing and treatment of extensive stage III or stage IV pressure sores. The department may grant a one-time, three-month extension if the provider can provide evidence that the wound is healing, but has not completely healed;
   
   
3. Services are limited to a maximum of one month when prescribed by a physician for postoperative healing of skin grafts and flap closures;
   
   
4. A low-air-loss bed or an air-fluidized system is limited to one which does not have a built-in scale;
   
   
5. Services must include weekly wound care consultation by the provider with consultation available 24 hours a day;
   
   
6. The provider must have prior written authorization from the department as provided under § 67:16:29:02.02; and
   
   
7. The provider must submit monthly documentation as provided under § 67:16:29:02.03 showing progress of the healing of the wound.
   
   

Prevention of pressure sores and pain control are services that are not covered under this section.

67:16:29:02.02. Pressure reduction therapy -- Requirements for prior authorization. When requesting prior authorization under subdivision 67:16:29:02.01(6), the provider must submit the following documentation to the department:

1. The physician's order prescribing the therapy, including the length of therapy;
   
   
2. A history of the skin breakdown, including methods of prevention and other treatment used prior to consideration of pressure reduction or low-air-loss bed therapy and the recipient's response to those methods or treatments;
   
   
3. The patient's status, including a description of the wound, its site, stage, size, depth, and drainage; wound treatments; general medical status and coexisting medical conditions; nutritional status and dietary consultation; recommended calorie intake with a summary of percent consumed; fluid intake; hydration; skin turgor; continence status; mobility status; and amount of time off the therapy and ability to ambulate and reposition; and
   
   
4. Pictures of the pressure sore.
   
   

67:16:29:02.03. Pressure reduction therapy -- Required documentation. The documentation required under subdivision 67:16:29:02.01(7) must include the following:

1. Physician's documentation outlining the patient's progress and the specific medical reasons for the continued need for pressure reduction therapy. Progressive wound healing must be documented for continued approval;
   
   
2. The patient's status, including a description of the wound, its site, stage, size, depth, and drainage; wound treatments; general medical status and coexisting medical conditions; nutritional status and dietary consultation; recommended calorie intake with a summary of percent consumed; fluid intake; hydration; skin turgor; continence status; mobility status; and amount of time off the therapy and ability to ambulate and reposition; and
   
   
3. Pictures showing the wound healing process.
   
   

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
  • Anticipated length of treatment
  • Description of the wound, its site, stage, size, depth, and drainage; wound treatments
  • General medical status and coexisting medical conditions; nutritional status and dietary consultation; recommended calorie intake with a summary of percent consumed; fluid intake; hydration; skin turgor; continence status
  • Mobility status; and amount of time off the therapy and ability to ambulate and reposition
  • Pictures of the pressure sore

Mail or fax your completed form and documentation to: