Provider resources forpre-authorization and more

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Services Requiring Authorization

Authorization Service Category	Comments
Admissions	ALL planned or scheduled inpatient admissions, includes medical, behavioral health, surgical admissions, hospice, including transfers from one facility to another
Acute Rehabilitation	ALL Inpatient Rehabilitation, Long Term Acute Care Hospital, Skilled Nursing Facilities
Ambulance or Air/Water Transport	Ambulance or Air/Water Ambulance (Non-Emergent) transport or transfer generally not covered
Any Experimental/ Investigational Services	Experimental/ Investigational medical and surgical procedures, equipment, and medications
Behavioral Health Services	Behavioral Health Services Applied Behavioral Analysis (ABA) Electroconvulsive Therapy (ECT) Applied Neuropsychological and Psychological Testing Intensive outpatient program (IOP) Partial Hospitalization (PHP) Residential treatment center (RTC)
Clinical trials	All clinical trials including cancer and clinical innovation
Dental	All dental related services. Generally not covered.
Dialysis	All services
Durable Medical Equipment & Prosthetics	All DME Rental Some items require authorization.
Hematology and Oncology	Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services
Imaging Advanced & Diagnostic Procedures	Arteriogram, Angiograms, CT/CTA scans, MRIs/MRAs, PET scans (exception breast MRI doesn’t require preauthorization)
Gene Therapy and Molecular Diagnostic Testing	Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services All gene therapy In network lab: Quest Diagnostics and Bioreference (see website for up to date in network provider information)
Home Services* (plan specific benefit) In network home health: see provider directory for up to date information	Home care Home infusion services Home hospice services after first 6 months Total parental nutrition Medical foods or enteral nutrition (oral foods generally not covered)
The following surgeries when performed in an Inpatient, Outpatient, or office location.	Includes: Back injections (ESI, RFA, MBB, Facet, ect.) Bariatric Surgery Blepharoplasty - Brow Lift Breast Procedures All Cosmetic surgery: not covered when performed to improve appearance All infusions Hyperbaric oxygen therapy Photodynamic therapy Spine Procedures Neurostimulators Ophthalmologic procedures Some Joint Surgeries (Knee, Hip, Shoulder) Some Ear Nose and Throat, Oral-Maxo facial, Integumentary, Gastrointestinal, Female and Male Genital, Reproductive, Ophthalmologic, Orthopedic, Neurological, Fertility CAR-T Cell therapy procedures
Miscellaneous, Unlisted Codes and T Codes	Miscellaneous, unlisted codes and T codes are not covered, unless otherwise stated in the provider’s contract.
Physician Administered Drugs: Some Specialty Rx/Infusions	Most drugs require prior authorization eg. biologicals, supportive care drugs, immunoglobulins, viscosupplementation, etc. Please see the list below for common examples, call Evry Health to confirm if physician administered drug is not listed below.
Plan Specific Provisions: Check member benefit/eligibility for eligibility.	Child Developmental Delays for rehabilitative and habilitative services Home Health which includes a limit to 60 visits per calendar year combined modalities Treatment of Mental or Emotional Illness or Disorder when confined to a hospital or Psychiatric Day Treatment Facility In-Vitro Fertilization/Fertility Speech and Hearing Assistance Bariatric Surgery Transgender Services
Transplants and Transplant related services	All Transplants Includes Transplant Evaluations, Pre- & Post- Operative Services/Care