67:16:42:03.  Enteral nutritional therapy for individual 21 years of age and older. Enteral nutritional therapy for an individual who is 21 years of age or older is covered if all of the following conditions are met:

          (1)  The individual is not institutionalized and services are delivered in the individual's residence. For purposes of this rule, an individual's residence does not include an acute care hospital, a nursing facility, an intermediate care facility for the mentally retarded, or an institution for individuals with a mental disease;

          (2)  The individual has a permanently inoperative internal body organ or an inoperative body function;

          (3)  There is a physician's order or prescription for the therapy and sufficient medical documentation describing the medical necessity for the therapy;

          (4)  The provider has received prior approval from the department; and

          (5)  Enteral nutritional therapy is the only means the individual has to receive nutrition.

          Enteral nutritional therapy is covered if the individual has a functioning gastrointestinal tract but cannot maintain weight and strength commensurate with the individual's general condition because of pathology to or the nonfunction of the structures that normally permit food to reach the digestive tract.

          Source: 22 SDR 32, effective September 11, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.