Download the evry health
pre-authorization request form.
Upload the evry health
pre-authorization request form.
Services Requiring Pre-Authorization
| Category | Service | Comments |
|---|---|---|
Acupuncture | Limted to 5 per calendar year. | See medical policy at evryhealth.com |
Admissions | All planned or scheduled inpatient medical, behavioral health and surgical admissions including acute, rehab, and skilled nursing facility. | Including transfers from one facility to another, intensive outpatient program (IOP), partial hospitalization (PHP), and residential treatment center (RTC). Exceptions: For maternity admission for vaginal delivery or C-section where notification is required within 24 hours or one business day of the admission. |
Ambulance or Air Transport | Non-emergent transport or transfer | Generally not covered. |
Bariatric Surgery | All services require prior authorization | Generally not covered. Plan specific benefit for initial and/or revision. |
Breast reconstruction | Post - mastectomy for breast cancer and revisions | Breast reductions also covered with medical necessity authorization. |
Clinical Trials | All clinical trials including cancer and clinical innovation | |
Chiropractic | Limited to 5 per calendar year. | See medical policy at evryhealth.com |
Dental | All dental related services | Generally not covered. |
DME/Devices Replacement of devices every 36 months | Durable medical equipment over $1000. Including orthotics and prosthetics | Evry's in network provider for DME is Apria |
Cochlear implants | ||
Hearing Aids |