Prior Authorization Requests
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization RequestsUPDATEDMarch 22PRIOR AUTHORIZATION REQUESTSOVERVIEWThis manual provides a list of services by services type and HCPCS code that require prior authorization. Inaddition to the services listed below, some services may require prior authorization for other reasonssuch as exceeding a service limit. Prior authorization criteria is listed in the applicable manual and links tothe criteria are provided below.South Dakota Medicaid has 30 days to make a prior authorization determination. However, in mostcircumstances’ authorizations can be completed in less time, usually around 2 weeks. Prior authorization isonly required for the elective services listed below. Urgent or emergent care is exempt from priorauthorization requirements. Retro authorizations can be requested after the service is provided if care wassuspected to be urgent/emergent at the time but will be billed as elective.If an inpatient hospitalization admission is the result of an emergent or urgent situation, or is a transfersituation, the Prior Authorization Request Form should be submitted within 48 hours and authorizationswill be expedited and completed within 2 business days of the request. No prior authorization is neededfor the transportation. Please refer to the transportation manuals for transportation coveragerequirements.Only one prior authorization is needed for a hospital stay. Physician and other licensed practitionerservices are included as part of the prior authorization for the inpatient stay. A prior authorization will beissued to the prior authorization contact for the inpatient facility for the dates of the approved hospitalstay. In addition to the hospital facility, this authorization must be shared with all physicians to use forvisits billed during that hospital stay.Most out-of-state services require prior authorization. For questions regarding services rendered by anout-of-state provider please refer to the Out-of-State Services Manual.REQUEST DOCUMENTATIONAll prior authorization request must be submitted with the following information: Appropriate prior authorization request form:o BRCAo Synagiso Applied Behavior Analysis Therapyo Private Duty Nursing & Extended Home Health Serviceso Durable Medical Equipmento Medical Nutritiono Out-of-State Serviceso Long Term Acute Care (LTAC) And Out-Of-State Rehabo Genetic Testingo Incontinence Supply Family Support 360 Waivero Incontinence Supply Supply HOPE Waivero Incontinence Supply ADLS Support 360 Waivero Incontinence Supply CHOICES Waivero General (Use if there is not a specific form for the requested service)PAGE 1
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization Requests UPDATEDMarch 22Medical documentation, including medical records, to support medical necessity;Prescriptions.Any additional documentation required by South Dakota Medicaid as listed in the priorauthorization criteria.SUBMISSIONPrior Authorizations requests should be submitted to South Dakota Medicaid via secure email. Usesecure email to send completed documentation to DSSMedicaidPA@state.sd.usIf secure email is unavailable, mail or fax completed documentation to:South Dakota Department of Social ServicesDivision of Medical ServicesAttn: Prior Authorization700 Governors DrivePierre SD 57501Fax – 605-773-5246DENIED REQUESTSRequests that are denied always include an explanation of the reason for denial, as well as instructionsfor recipients to exercise the right to appeal within 30 days of the date of the letter if desired. Providersmay make a second prior authorization request with new medical records or documentation. Any timenew requests and records are submitted, South Dakota Medicaid will consider the new records to makea new prior authorization determination.SERVICES REQUIRING PRIOR A UTHORIZATION BY S ERVICE TYPEServiceApplied Behavior Analysis(ABA) Therapy ServicesBariatric SurgeryCriteria LocationApplied Behavior AnalysisServicesSurgical ServicesBone Growth StimulatorsDurable Medical Equipment,Prosthetics, Orthotics andSuppliesPhysician Administered Drugs,Vaccines and ImmunizationsDurable Medical Equipment,Prosthetics, Orthotics andSuppliesBotoxBreast Pump (Hospital GradeElectric Breast Pump)FormPrior Authorization RequestFormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormPAGE 2
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization RequestsUPDATEDMarch 22Breast ReconstructionSurgical ServicesBreast ReductionSurgical ServicesCare Management ForRehabilitation UnitsCare Management PsychiatricUnitsInpatient Hospital ServicesInpatient Hospital ServicesCochlear ImplantSurgical ServicesContinuous GlucoseMonitoring PolicyDurable Medical Equipment,Prosthetics, Orthotics andSuppliesSurgical ServicesContinuous Passive MotionDevicesCough Stimulating DevicesEPSDTDurable Medical Equipment,Prosthetics, Orthotics andSuppliesWell Child, Well Adult, andOther Preventative ServicesGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormOut-of-State Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGait TrainersGenetic TestingDurable Medical Equipment,Prosthetics, Orthotics andSuppliesLaboratory and PathologyServicesNutrition Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGenetic Testing PriorAuthorization Request FormBRCA Testing PriorAuthorization Request FormHigh Frequency Chest WallCompression OrIntrapulmonary PercussiveVentilation DevicesDurable Medical Equipment,Prosthetics, Orthotics andSuppliesDME Prior AuthorizationRequest FormPAGE 3
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization RequestsUPDATEDMarch 22HydroxyprogesteroneCaproate (Makena )Hyperbaric Oxygen TherapyPhysician Administered Drugs,Vaccines and ImmunizationsOutpatient Hospital ServicesHysterectomySterilizationImplanted Nerve StimulatorsSurgical ServicesLong Term Acute CareInpatient Hospital ServicesLow Air Loss / PressureReduction TherapyDurable Medical Equipment,Prosthetics, Orthotics andSuppliesDurable Medical Equipment,Prosthetics, Orthotics andSuppliesOutpatient Hospital ServicesLymphedema PumpsMagnetoencephalography(Meg) And Magnetic SourceImaging (Msi)Medically Complex / RehabFor ChildrenMental Health Visits BeyondThe Coverage LimitMental Health Visits ForChildren Under 2 Years OfAgeNegative Pressure WoundTherapy Pumps V.A.C.Neonatal Intensive Care UnitNutrition TherapyInpatient Hospital ServicesIndependent Mental HealthPractitionersCommunity Mental HealthCentersDurable Medical Equipment,Prosthetics, Orthotics andSuppliesInpatient Hospital ServicesOut-Of-State ServicesNutritional Therapy Servicesand Nutrition SupplementsOut-of-State ProvidersPanniculectomySurgical ServicesPrivate Duty NursingPrivate Duty NursingGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormHysterectomyAcknowledgement ofInformationGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormNutrition Prior AuthorizationRequest FormOut-of-State Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormPrivate Duty Nursing &Extended Home HealthServices Prior AuthorizationRequest FormPAGE 4
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization RequestsUPDATEDMarch 22Psychiatric ResidentialTreatment Facilities (PRTF)Psychiatric ResidentialTreatment FacilitiesQuestionably CosmeticProceduresRemoval Of Excess SkinSurgical ServicesSpecialty Mobility DevicesDurable Medical Equipment,Prosthetics, Orthotics andSuppliesDurable Medical Equipment,Prosthetics, Orthotics andSuppliesSurgical ServicesSpeech Generating DeviceSpinal SurgerySterilizationSynagisSurgical ServicesSterilizationPhysician Administered Drugs,Vaccines and ImmunizationsSurgical ServicesTransplantsState Review Team FacilitatorMegan NewlingPhone: 605-773-3448General Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormDME Prior AuthorizationRequest FormGeneral Prior AuthorizationRequest FormSterilization Consent FormPrior Authorization FormGeneral Prior AuthorizationRequest FormSERVICES REQUIRING PRIOR A UTHORIZATION BY 7015769157711577215773DescriptionOncology (Urothelial), Mrna, Gene Expression Profiling By Real-Time QuantitativePcr Of Five Genes (Mdk, Hoxa13, Cdc2 [Cdk1], Igfbp5, And Cxcr2), Utilizing Urine,Algorithm Reported As A Risk Score For Having Urothelial CarcinomaOncology (Urothelial), Mrna, Gene Expression Profiling By Real-Time QuantitativePcr Of Five Genes (Mdk, Hoxa13, Cdc2 [Cdk1], Igfbp5, And Cxcr2), Utilizing Urine,Algorithm Reported As A Risk Score For Having Recurrent Urothelial CarcinomaCollagen Cross-Linking Treatment Of Disease Of CorneaIntroduction Of Pigment Into Skin (6.1 To 20.0 Sq Cm) To Correct Color DefectInjection Of 1.1 To 5.0 Cc Filling Material, Beneath The SkinInjection Of Over 10.0 Cc Filling Material, Beneath The SkinReplacement Of Tissue Expander With Permanent ImplantGrafting Of Patient Soft Tissue, Harvested By Direct ExcisionGrafting Of Patient Fat, Harvested By Liposuction To Trunk, Breasts, Scalp, Arms,And/Or Legs; 50 Cubic Centimeters Or LessGrafting Of Patient Fat, Harvested By Liposuction To Trunk, Breasts, Scalp, Arms,And/Or Legs; Additional 50 Cubic Centimeters Or LessGrafting Of Patient Fat, Harvested By Liposuction To Face, Eyelids, Mouth, Neck,Ears, Orbits, Genitalia, Hands, And/Or Feet; 25 Cc Or Less InjectatePAGE 5
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 193962093020931UPDATEDMarch 22DescriptionGrafting Of Patient Fat, Harvested By Liposuction To Face, Eyelids, Mouth, Neck,Ears, Orbits, Genitalia, Hands, And/Or Feet; Each Additional 25 Cc Or LessInjectateChemical Peel Of Skin Of Face, Outer LayerChemical Peel Of Skin Of Face, Deep LayerBlepharoplasty, Upper Eyelid; With Excessive Skin Weighting Down LidExcision, Excessive Skin And Subcutaneous Tissue (Includes Lipectomy);Abdomen, Infraumbilical PanniculectomyExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) ThighExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) LegExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) HipExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) ButtockExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) ArmExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) ForearmOr HandExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy)Submental Fat PadExcision, Excessive Skin And Subcutaneous Tissue (Including Lipectomy) OtherAreaSuction Assisted Lipectomy; Head And NeckSuction Assisted Lipectomy; TrunkSuction Assisted Lipectomy; Upper ExtremitySuction Assisted Lipectomy; Lower ExtremityMastectomy For GynecomastiaRepair For Sagging Of The BreastBreast ReductionInsertion Of Breast ImplantRemoval Of Intact Breast ImplantRemoval Of Ruptured Breast Implant And Implant MaterialImmediate Insertion Of Breast Implant On Same Day As MastectomyDelayed Insertion Of Breast Implant After MastectomyNipple/Areola ReconstructionCorrection Of Inverted NipplesReconstruction Of Breast Using Tissue ExpanderReconstruction Of Breast With Back Muscle FlapReconstruction Of Breast With Free FlapReconstruction Of Breast With Abdominal Muscle FlapReconstruction Of Breast With Single-Based Abdominal Muscle FlapReconstruction Of Breast With Double-Based Abdominal Muscle FlapSurgical Change To Tissue Capsule Surrounding Breast ImplantRemoval Of Entire Tissue Capsule Surrounding Breast ImplantSurgical Change To Reconstructed BreastPreparation Of Moulage For Custom Breast ImplantFragmented Donor Bone Graft Or Placement Of Material To Promote Bone GrowthFor Spine SurgeryStructural Donor Bone Graft For Spine SurgeryPAGE 6
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 2280422808UPDATEDMarch 22DescriptionAutograft For Spine Surgery Only (Includes Harvesting The Graft); Local (Eg, Ribs,Spinous Process, Or Laminar Fragments) Obtained From Same Incision (ListSeparately In Addition To Code For Primary Procedure)Harvest Of Bone Marrow For Spine Surgery GraftReduction Forehead; Contouring OnlyReduction Forehead; Contouring And Application Of Prosthetic Material Or BoneGraft (Includes Obtaining Autograft)Fusion Of Middle Spine Bones With Removal Of Disc, Lateral ApproachFusion Of Lower Spine Bones With Removal Of Disc, Lateral ApproachFusion Of Spine Bones At Base Of Neck, Oral ApproachFusion Of Spine Bones With Removal Of Disc At Upper Spinal Column, AnteriorApproach, ComplexFusion Of Spine Bones With Removal Of Disc In Upper Spinal Column BelowSecond Vertebra Of Neck , Anterior ApproachFusion Of Spine Bones With Removal Of Disc At Upper Spinal Column, AnteriorApproach, SimpleFusion Of Middle Spine Bones With Removal Of Disc, Anterior ApproachFusion Of Spine Bones With Removal Of Disc At Lower Spinal Column, AnteriorApproachFusion Of Spine Bones With Removal Of Disc, Anterior ApproachArthrodesis, Pre-Sacral Interbody Technique, Including Disc Space Preparation,Discectomy, With Posterior Instrumentation, With Image Guidance, Includes BoneGraft When Performed, L5-S1 InterspaceFusion Of First Two Upper Spine Bones Of Spinal Column, Posterior ApproachFusion Of Spine Bones At Skull Base, Posterior ApproachFusion Of Upper Spine Bones, Posterior Or Posterolateral ApproachFusion Of Middle Spine Bones, Posterior Or Posterolateral ApproachFusion Of Lower Spine Bones, Posterior Or Posterolateral ApproachFusion Of Spine Bones, Posterior Or Posterolateral ApproachFusion Of Lower Spine Bones With Removal Of Disc, Posterior Approach, SingleInterspaceFusion Of Lower Spine Bones With Removal Of Disc, Posterior Approach, SingleInterspace, Each Additional InterspaceFusion Of Lower Spine Bones With Removal Of Disc, Posterior Or PosterolateralApproach, Single Interspace And SegmentFusion Of Lower Spine Bones With Removal Of Disc, Posterior Or PosterolateralApproach, Single Interspace And Segment, Each Additional Interspace AndSegmentFusion Of Spine Bones For Correction Of Deformity, Posterior Approach, Up To 6Vertebral SegmentsFusion Of Spine Bones For Correction Of Deformity, Posterior Approach, 7 To 12Vertebral SegmentsFusion Of Spine Bones For Correction Of Deformity, Posterior Approach, 13 OrMore Vertebral SegmentsFusion Of Spine Bones For Correction Of Deformity, Anterior Approach, 2 To 3Vertebral SegmentsPAGE 7
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 2286722868228692287022899UPDATEDMarch 22DescriptionFusion Of Spine Bones For Correction Of Deformity, Anterior Approach, 4 To 7Vertebral SegmentsFusion Of Spine Bones For Correction Of Deformity, Anterior Approach, 8 Or MoreVertebral SegmentsFusion Of Spine Bones For Correction Of Hunchback Deformity, Single Or 2SegmentsFusion Of Spine Bones For Correction Of Hunchback Deformity, 3 Or MoreSegmentsExploration Of Spinal FusionInsertion Of Posterior Spinal Instrumentation At Base Of Neck For Stabilization, 1InterspaceInternal Spinal Fixation By Wiring Of Spinous Processes (List Separately InAddition To Code For Primary Procedure)Insertion Of Posterior Spinal Instrumentation For Spinal Stabilization, 3 To 6Vertebral SegmentsInsertion Of Posterior Spinal Instrumentation For Spinal Stabilization, 7 To 12Vertebral SegmentsInsertion Of Posterior Spinal Instrumentation For Spinal Stabilization, 13 Or MoreVertebral SegmentsInsertion Of Anterior Spinal Instrumentation For Spinal Stabilization, 2 To 3Vertebral SegmentsInsertion Of Anterior Spinal Instrumentation For Spinal Stabilization, 4 To 7Vertebral SegmentsInsertion Of Anterior Spinal Instrumentation For Spinal Stabilization, 8 Or MoreVertebral SegmentsPelvic Fixation (Attachment Of Caudal End Of Instrumentation To Pelvic BonyStructures) Other Than Sacrum (List Separately In Addition To Code For PrimaryProcedure)Reinsertion Of Spinal Fixation DeviceRemoval Of Posterior Nonsegmental Spinal InstrumentationRemoval Of Posterior Segmental Spinal InstrumentationRemoval Of Anterior Instrumentation (Eg, Dwyer Device)Insertion Of Artificial Upper Spine Disc, Anterior ApproachInsertion Of Artificial Lower Spine Disc, Anterior ApproachInsertion Of Artificial Upper Spine Disc Anterior ApproachInsertion Of Device Into Gap Left By Removal Of Part Of VertebraRevision With Replacement Of Artificial Upper Spine DiscRevision With Replacement Of Artificial Lower Spine DiscRevision Of Artificial Upper Spine Disc, CervicalRevision Of Artificial Lower Spine Disc, LumbarInsertion Of Stabilizing Or Separating Device Into Lower Spine At Single Level WithOpen DecompressionInsertion Of Stabilizing Or Separating Device Into Lower Spine At Additional LevelWith Open DecompressionInsertion Of Stabilizing Or Separating Device Into Lower Spine At Single LevelInsertion Of Stabilizing Or Separating Device Into Lower Spine At Second LevelUnlisted Procedure, SpinePAGE 8
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 377603776137765377663778037785UPDATEDMarch 22DescriptionRepair Of Collapsed Nostril Using Implant In Side Of NoseDilation Of Sphenoid And Frontal Sinus In The Nose Using An EndoscopeDonor Pneumonectomy (Including Cold Preservation), From Cadaver DonorLung Transplant, Single; Without Cardiopulmonary BypassLung Transplant, Single; With Cardiopulmonary BypassLung Transplant, Double (Bilateral Sequential Or En Bloc); WithoutCardiopulmonary BypassLung Transplant, Double (Bilateral Sequential Or En Bloc); With CardiopulmonaryBypassImplantation Of Artificial HeartReplacement Of Artificial HeartHeart-Lung Transplant With Recipient Cardiectomy-PneumonectomyHeart Transplant, With Or Without Recipient CardiectomyInjection Of Chemical Agent Into Single Incompetent Vein Of Leg Using UltrasoundGuidanceInjection Of Chemical Agent Into Multiple Incompetent Veins Of Same Leg UsingUltrasound GuidanceInjection Of Chemical Agent Into Spider Veins Of Arm, Leg, Or TrunkInjection Of Chemical Agent Into Single Incompetent VeinInjection Of Chemical Agent Into Multiple Incompetent Veins Of One LegDestruction Of Insufficient Vein Of Arm Or Leg, Accessed Through The SkinRadiofrequency Destruction Of Insufficient Vein Of Arm Or Leg, Accessed ThroughThe Skin Using Imaging GuidanceLaser Destruction Of Incompetent Vein Of Arm Or Leg Using Imaging Guidance,Accessed Through The SkinLaser Destruction Of Insufficient Vein Of Arm Or Leg, Accessed Through The SkinUsing Imaging GuidanceChemical Destruction Of Incompetent Vein Of Arm Or Leg, Accessed Through TheSkin Using Imaging GuidanceChemical Destruction Of Incompetent Vein Of Arm Or Leg, Accessed Through TheSkin Using Imaging Guidance, Subsequent Vein(S)Mechanical Separation Of Plasma And Abnormal Antibodies From BloodLigation, Division, And Stripping, Short Saphenous VeinLigation, Division, And Stripping, Long (Greater) Saphenous Veins FromSaphenofemoral Junction To Knee Or BelowLigation And Division And Complete Stripping Of Long Or Short Saphenous VeinsWith Radical Excision Of Ulcer And Skin Graft And/Or Interruption OfCommunicating Veins Of Lower Leg, With Excision Of Deep FasciaTying Of Varicose Veins In One Leg, Open Procedure, RadicalTying Of Varicose Veins In One Leg, Open Procedure, SimpleMultiple Incisions For Removal Of Varicose Veins Of Arm Or Leg, 10-20 IncisionsMultiple Incisions For Removal Of Varicose Veins Of Arm Or Leg, Greater Than 20IncisionsTying And Incision Leg Vein, Short Saphenous VeinLigation, Division, And/Or Excision Of Recurrent Or Secondary Varicose Veins(Clusters), One LegPAGE 9
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 438824388643887UPDATEDMarch 22DescriptionBlood-Derived Hematopoietic Progenitor Cell Harvesting For Transplantation, PerCollection; AllogenicBlood-Derived Hematopoietic Progenitor Cell Harvesting For Transplantation, PerCollection; AutologousHarvesting Of Donor Bone Marrow For TransplantationTransplantation Of Donor Stem Cells, Per DonorTransplantation Of Patient-Derived Stem CellsTransplantation Of Donor White Cells (Lymphocytes)Gastrectomy, Partial, Distal; With Roux-En-Y ReconstructionLaparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass AndRoux-En-Y Gastroenterostomy (Roux Limb 150 Cm Or Less)Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass AndSmall Intestine Reconstruction To Limit AbsorptionLaparoscopy, Surgical; Implantation Or Replacement Of Gastric NeurostimulatorElectrodes, AntrumLaparoscopy, Surgical; Revision Or Removal Of Gastric NeurostimulatorElectrodes, AntrumUnlisted Laparoscopy Procedure, StomachLaparoscopy, Surgical, Gastric Restrictive Procedure; Placement Of AdjustableGastric Restrictive Device (Eg, Gastric Band And Subcutaneous Port Components)Laparoscopy, Surgical, Gastric Restrictive Procedure; Revision Of AdjustableGastric Restrictive Device Component OnlyLaparoscopy, Surgical, Gastric Restrictive Procedure; Removal Of AdjustableGastric Restrictive Device Component OnlyLaparoscopy, Surgical, Gastric Restrictive Procedure; Removal And ReplacementOf Adjustable Gastric Restrictive Device Component OnlyLaparoscopy, Surgical, Gastric Restrictive Procedure; Removal Of AdjustableGastric Restrictive Device And Subcutaneous Port ComponentsLaparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy(Ie, Sleeve Gastrectomy)Gastric Restrictive Procedure, Without Gastric Bypass, For Morbid Obesity;Vertical-Banded GastroplastyGastric Restrictive Procedure, Without Gastric Bypass, For Morbid Obesity; OtherThan Vertical-Banded GastroplastyPartial Removal Of Stomach, With Partial GastrectomyPartial Removal Of Stomach, With GastroenterostomyPartial Removal Of Stomach, With Small Intestine RepairRevision Of Upper Stomach Bypass, Open ProcedureRevision Of Gastroduodenal Anastomosis (Gastroduodenostomy) WithReconstruction; Without VagotomyReplacement Of Stimulator Electrodes In Upper Stomach, Open ProcedureRemoval Of Stimulator Electrodes In Upper Stomach, Open ProcedureRevision Of Port Beneath Skin For Saline Injection Into Stomach Banding Device,Open ProcedureRemoval Of Port Beneath Skin For Saline Injection Into Stomach Banding Device,Open ProcedurePAGE 10
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization ch 22DescriptionReplacement Of Port Beneath Skin For Saline Injection Into Stomach BandingDevice, Open ProcedurePartial Removal Of Donor Small Bowel For Transplantation, Open ProcedureIntestinal Allotransplantation; From Living DonorTransplantation Of Donor Liver To Anatomic PositionPancreatectomy, Total Or Subtotal, With Autologous Transplantation Of PancreasOr Pancreatic Islet CellsDonor Pancreatectomy (Including Cold Preservation), With Or Without DuodenalSegment For TransplantationBackbench Standard Preparation Of Cadaver Donor Pancreas Allograft Prior ToTransplantation, Including Dissection Of Allograft From Surrounding Soft Tissues,Splenectomy, Duodenotomy, Ligation Of Bile Duct, Ligation Of Mesenteric Vessels,And Y-GrPreparation Of Donor Pancreas For Transplantation, EachTransplantation Of Pancreatic AllograftRemoval Of Transplanted Pancreatic AllograftUnlisted Procedure, PancreasClitoroplasty For Intersex StateInsertion Or Replacement Of Brain Neurostimulator Generator Or Receiver WithConnection To A Single ElectrodeInsertion Or Replacement Of Brain Neurostimulator Generator Or Receiver WithConnection To Multiple ElectrodesLaminectomy With Exploration And/Or Decompression Of Spinal Cord And/OrCauda Equina, Without Facetectomy, Foraminotomy Or Diskectomy, (Eg, SpinalStenosis), One Or Two Vertebral Segments; CervicalPartial Removal Of Spinal Bone With Exploration And/Or Decompression Of SpinalCord In Upper BackPartial Removal Of Spinal Bone With Exploration And/Or Decompression Of SpinalCord In Lower BackLaminectomy For Decompression Of Spinal Cord And/Or Cauda Equina, One OrTwo Segments; SacralLaminectomy With Removal Of Abnormal Facets And/Or Pars Inter-Articularis WithDecompression Of Cauda Equina And Nerve Roots For Spondylolisthesis, Lumbar(Gill Type Procedure)Laminectomy With Exploration And/Or Decompression Of Spinal Cord And/OrCauda Equina, Without Facetectomy, Foraminotomy Or Diskectomy, (Eg, SpinalStenosis), More Than 2 Vertebral Segments; CervicalPartial Removal Of Bone And/Or Release Of Middle Spinal Cord Or Spinal Nerves,More Than 2 Vertebral SegmentsPartial Removal Of Bone And/Or Release Of Lower Spinal Cord Or Spinal Nerves,More Than 2 Vertebral SegmentsLaminotomy (Hemilaminectomy), With Decompression Of Nerve Root(S), IncludingPartial Facetectomy, Foraminotomy And/Or Excision Of Herniated IntervertebralDisc; 1 Interspace, CervicalLaminotomy (Hemilaminectomy), With Decompression Of Nerve Root(S), IncludingPartial Facetectomy, Foraminotomy And/Or Excision Of Herniated IntervertebralDisc; 1 Interspace, LumbarPAGE 11
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 630756307663077UPDATEDMarch 22DescriptionLaminotomy (Hemilaminectomy), With Decompression Of Nerve Root(S), IncludingPartial Facetectomy, Foraminotomy And/Or Excision Of Herniated IntervertebralDisc; Each Additional Interspace, Cervical Or Lumbar (List Separately In AdditionTo Code For PrimaryRe-Exploration Of Spine Repair With Release Of Upper Spinal Cord Or Nerves,Single InterspaceRe-Exploration Of Spine Repair With Release Of Lower Spinal Cord Or Nerves,Single InterspaceRe-Exploration Of Spine Repair With Release Of Upper Spinal Cord Or Nerves,Each Additional Cervical InterspaceRe-Exploration Of Spine Repair With Release Of Lower Spinal Cord Or Nerves,Each Additional Lumbar InterspaceLaminectomy, Facetectomy And Foraminotomy (Unilateral Or Bilateral WithDecompression Of Spinal Cord, Cauda Equina And/Or Nerve Root(S), (Eg, SpinalOr Lateral Recess Stenosis), Single Vertebral Segment; CervicalPartial Removal Of Middle Spine Bone With Release Of Spinal Cord And/OrNerves, Mid Back (Thoracic) AreaPartial Removal Of Middle Spine Bone With Release Of Spinal Cord And/OrNerves, Lower Back (Lumbar) AreaLaminectomy, Facetectomy And Foraminotomy (Unilateral Or Bilateral WithDecompression Of Spinal Cord, Cauda Equina And/Or Nerve Root(S), (Eg, SpinalOr Lateral Recess Stenosis)), Single Vertebral Segment; Each Additional Segment,Cervical, Thoracic, Or LumbaLaminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or MoreVertebral Segments;Reconstruction Of Bone Around Spinal Canal With Release Of Spinal Cord, WithBone ReconstructionRelease Of Middle Spinal Cord And/Or NervesTranspedicular Approach With Decompression Of Spinal Cord, Equina And/OrNerve Root(S) (Eg, Herniated Intervertebral Disk), Single Segment; Lumbar(Including Transfacet, Or Lateral Extraforaminal Approach) (Eg, Far LateralHerniated Intervertebral Disk)Transpedicular Approach With Decompression Of Spinal Cord, Equina And/OrNerve Root(S) (Eg, Herniated Intervertebral Disk), Single Segment; Each AdditionalSegment, Thoracic Or Lumbar (List Separately In Addition To Code For PrimaryProcedure)Release Of Middle Spinal Cord Or Nerves, Costovertebral Approach, SingleSegmentRelease Of Middle Spinal Cord Or Nerves, Costovertebral Approach, EachAdditional SegmentRemoval Of Upper Spine Disc And Release Of Spinal Cord And/Or Nerves, SingleInterspaceRemoval Of Upper Spine Disc And Release Of Spinal Cord And/Or Nerves, EachAdditional InterspaceRemoval Of Middle Spine Disc And Release Of Spinal Cord And/Or Nerves, SingleInterspacePAGE 12
SOUTH DAKOTA MEDICAIDBILLING AND POLICY MANUALPrior Authorization 81180UPDATEDMarch 22DescriptionRemoval Of Middle Spine Disc And Release Of Spinal Cord And/Or Nerves, EachAdditional InterspaceRemoval Of Spine Bone With Severing Of Nerve Roots, 1 Or 2 SegmentsRemoval Of Spine Bone With Severing Of Nerve Roots, More Than 2 SegmentsLaminectomy With Section Of Spinal Accessory NerveRemoval Of Spine Bone With Incision Of One Upper Spinal Cord TractRemoval Of Spine Bone With Incision Of One Middle Spinal Cord TractRemoval Of Spine Bone With Incision Of Both
Intrapulmonary Percussive Ventilation Devices Durable Medical Equipment, Prosthetics, Orthotics and Supplies DME Prior Authorization Request Form. SOUTH DAKOTA MEDICAID BILLING AND POLICY MANUAL Prior Authorization Requests UPDATED March 22 PAGE 4 Hydroxyprogesterone
Authorization for Services to Children Enrolled in CMS Safety Net Program 5 Section 2.0. Process for Requesting Prior Authorization 7 2.0.1. Submitting Prior Authorization Requests 7 2.0.2. Response Time for Prior Authorization Requests 7 2.0.3. Appeal Process for Denied, Reduced, Suspended, or Termination of Services 8 .
4 For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient. Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required.
Gold-Carding Gold-carding: A process that exempts providers with a record of consistent adherence to prior authorization criteria from prior authorization submission requirements Promotes more timely access to care by eliminating unnecessary obstacles between patients and treatments. Allows health plans to focus prior authorization on
Jane Doe with authorization code 654321 and authorization level 2 . Joe user with authorization code 999999 and authorization level 1 . Step 2.-Configuring Forced Authorization Codes . Go to the administration page of Cisco Unified Comm unications Manager, select Call Routing TAB, then select Force Authorization Codes as shown in the image s below.
preferred medication in one of three different ways: 1. Download and fax 4TUPrior Authorization Request Form U4T to 1(855) 811-9331 for both standard and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form.
Agenda 1012 MHS Prior Authorization 101 InterQual Connect Overview Prior Authorization (PA) Job Functions Behavioral Health Prior Authorization NICU
Forteo (Teriparatide) Clinical Criteria Information Included in this Document Forteo (Teriparatide) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior
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