Prior Authorization Request Services and Forms
Removal of excess skin
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.
67:16:01:08. Services not covered. In addition to items and services specified as not covered in other sections of this article, the following are examples of items and services not covered under the medical assistance program:
Cosmetic surgery to improve the appearance of an individual when not incidental to prompt repair following an accidental injury or any cosmetic surgery which goes beyond that which is necessary for the improvement of the functioning of a malformed body member;
Documentation Requirements for Prior Authorization Requests:
- General Prior Authorization Request Form
- Surgical Evaluation
- Applicable medical records describing problems related to excessive skin and conservative treatments tried.
- Pictures of the excessive skin.
Mail or fax your completed form and documentation to:
Division of Medical Services
700 Governors Drive
Pierre, SD 57501