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Prior Authorization

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:

Nurse Consultant
Division of Medical Services
700 Governors Drive
Pierre, SD 57501
605-773-3495
Fax 605-773-5246