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Rule 67:16:42:04 Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required.

          67:16:42:04.  Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required. The use of enteral nutritional therapy for an individual 21 years of age or older must be authorized by the department before the service is payable under this chapter. Authorization may only be given if the physician has provided sufficient medical documentation, including a written order or prescription, to the department describing the diagnosis and the medical necessity for the therapy.


          Prior authorization and a new prescription are required annually. If an initial authorization or an annual reauthorization is being requested or if there is a change in the physician's orders, documentation must include the following:


          (1)  A copy of the prescription for the needed therapy;

          (2)  A copy of the physician's statement giving the reasons the person is unable to receive adequate nutrition by normal means;

          (3)  The applicable procedure codes for the items and services provided;

          (4)  The provider's usual and customary charge for the items or services, including formula, durable medical equipment, and supplies; and

          (5)  Documentation regarding other requested routine medical services, such as home health services.


          If there is no change in the physician's orders and an annual reauthorization is being requested, documentation need only include the physician's certification that the individual continues to need the nutritional therapy.


          The department may verbally authorize services when the required information is transmitted to the department. The department shall verify a verbal authorization in writing following receipt of the required written documentation.


          Source: 22 SDR 32, effective September 11, 1995; 35 SDR 49, effective September 10, 2008; 40 SDR 122, effective January 7, 2014.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.


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