Prior Authorization Request Services and Forms

Spinal Surgery

The South Dakota Medical Assistance program will require prior authorization for all elective spinal surgeries. Surgeries involving acute traumatic injury, surgical treatment for malignant disease of the spine or primary infections of the spine will not require prior authorization.

Approval will be considered after review of documentation of the following:

1. Abnormal physical findings and/or functional limitations recorded in the medical record;
2. Reports of all diagnostic procedures done in the course of evaluation; and
3. Response to conservative management over 3 months including any physical therapy, exercise programs, activity modification, and/or injections in the absence of progressive neurological symptoms.
4. If the recipient is a tobacco user, tobacco use must be discontinued for 3 months prior to the surgery with documentation in the medical record.

The codes for procedures that require prior authorization in the above circumstances are: 

22548, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840-49, 22851-65, 22899, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042-49, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075-78, 63180, 63182, 63185, 63190, 63191, 63194-99, 63200

This is not considered an exclusive list and codes may change as new procedures become available or CPT codes are modified.

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form
• Medical record documentation

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