Neighborhood Health Plan DME & Exclusions Policy Update

Not Covered / Exclusions

inv-01: Not Covered / Exclusions

Services and items listed below are not covered unless otherwise specified by other policy or state regulation.

Investigational/Experimental: Drug or device that lacks FDA approval; requested treatment that is part of Phase I or II clinical trials or investigational arm of Phase III trials; services delivered in connection with or required by a non-covered item or service (exception: investigational services are covered for cancer per State regulation).

DME-specific exclusions: Purchase, repair, or replacement of DME resulting from enrollee abuse; purchase/repair/replacement of materials or equipment that has been stolen or destroyed except when documentation is provided (explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and copy of police/fire/insurance report if applicable); repair of DME items not covered by Neighborhood; repair of DME items covered under provider/manufacturer warranty; repair of rented DME items.

Non-DME household items: Air conditioners; air cleaners, purifiers or HEPA filters; dehumidifiers; floor mats; trampolines (including mini trampolines); suspension swings; hypoallergenic pillows/bedding; standard car seats; food and food products for specialty diets; waterproof casts and similar home items are not covered.

Cosmetic services: Procedures, supplies, devices, and associated professional and facility services intended to change or improve appearance without significant physiological benefit are not covered. Examples include cervicoplasty, chemical peels/exfoliation/dermabrasion, augmentation mammoplasty, mastopexy, excision of excess skin (e.g., abdominoplasty) except panniculectomy, genioplasty, gynecomastia surgery, hair removal/transplants, inverted nipple surgery, laser treatments for acne/scars, liposuction, osteoplasty, otoplasty, rhinoplasty, rhytidectomy (facelift), scar revision, tattooing/tattoo removal (except nipple/areola after mastectomy), testicular prosthesis, and related drugs/biologics and charges associated with cosmetic surgery.

Dental: Orthodontia and all dental services other than emergency dental care and limited oral surgery are not covered.

Home modifications: Permanent home modifications and structural items (decks; permanent lifts; enlarged doorways; environmental accessibility modifications such as grab bars and ramps; fences; handrails; room additions/expansions; telephone alert systems/service) are not covered.

Infertility exclusions: Infertility-related exclusions include: services for members who do not meet the definition of infertility; experimental infertility procedures; costs of surrogacy or gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation beyond 90 days unless member is in active infertility treatment, maternity care for non-member surrogate); donor recruitment/compensation; donor sperm and associated lab services without diagnosed male factor infertility; procurement of frozen donor oocytes; services for couples with prior sterilization (with or without reversal); and related limitations (short-term cryopreservation <90 days may be authorized in certain medical conditions).

Alternative therapies: Animal therapy, dance therapy, massage therapy, psychodrama, yoga, transcendental meditation and similar alternative/holistic therapies are not covered.

Additional general exclusions: Other non-covered items and services include academic performance testing; altered auditory feedback devices; chronic care management services; diagnostic tests to evaluate need for non-covered services; drugs/devices for sexual or erectile dysfunction (except medically necessary for organic conditions); educational testing/training programs; health club memberships; LASIK; medical alert ID bracelets; medical marijuana; personal emergency response systems; planned home births; respite care (except hospice); services provided outside the United States; sperm banking; vocational rehabilitation; wigs (except for alopecia and cancer treatment); lodging; transportation by chair car/wheelchair van/taxi; and numerous miscellaneous provider or convenience charges.

inv-02: Not covered / Excluded services

The following services, supplies, and procedures are explicitly not covered unless otherwise specified by law or stated exception.

Infertility-related exclusions: Infertility treatment is not covered for members who do not meet the definition of infertility; experimental infertility procedures; reversal of voluntary sterilization; costs of surrogacy/gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation beyond 90 days unless in active treatment, use of donor egg with gestational carrier, maternity care for non-member surrogate); donor recruitment/compensation; procurement of frozen donor oocytes; donor sperm and lab services in the absence of diagnosed male factor infertility; services related to prior sterilization procedures.

Cosmetic services exclusions: Procedures or services to change or improve appearance without significant physiological benefit are not covered. Specific exclusions include cervicoplasty, chemical peels/exfoliation/dermabrasion, augmentation mammoplasty, mastopexy, excision of excess skin (e.g., abdominoplasty except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplants, inverted nipple surgery, laser treatment for acne/scars, liposuction, otoplasty, rhinoplasty, rhytidectomy, scar revision, tattooing/tattoo removal (except nipple/areola for mastectomy), testicular prosthesis, osteoplasty, and related supplies and charges.

Alternative/complementary therapies not covered:

inv-03: Exclusions and non-covered services

The following services, settings, and items are excluded from coverage under this policy:

Settings and network: Services must be rendered by network providers unless it is an emergency or prior approval has been received; services, programs, supplies or procedures provided in nonconventional settings (e.g., spas/resorts, educational/vocational/recreational settings, wilderness programs) or performed outside the United States are excluded even if performed by licensed providers.

Lodging is not covered even when related to receiving any medical service.

Specific excluded categories: Over-the-counter contraceptive agents; pediatric vision services/supplies not meeting standards (including replacement for lost/stolen eyewear, plano lenses); reversal of voluntary sterilization; sexual/erectile dysfunction treatments except medically necessary for organic conditions; sexual reassignment/gender dysphoria related exclusions (cryopreservation/storage/thawing of reproductive tissue, voice modification surgery, reversal of genital surgery; procedures to alter body contours for aesthetic reasons are considered cosmetic and excluded except specified exceptions); transportation by chair car/wheelchair van/taxi; and numerous miscellaneous exclusions such as personal emergency response systems, TENS units and other neuromuscular stimulators, waterproof casts, medical marijuana, weight loss programs, and other items listed under general exclusions.

inv-04: Non-covered Services

The following codes and code ranges are identified as non-covered under the Integrity/Commercial sections in this fragment.

Non-covered codes: All CPT, HCPCS, and ICD-10-PCS codes and code ranges listed in the sections titled 'Non-Covered Services: INTEGRITY' and 'Non-Covered Services: Commercial' within this document are considered non-covered. See coding tables in the policy for the specific code listings and ranges.

The policy explicitly excludes non‑medical household items from coverage. Examples listed include air conditioners (window or central), air cleansers/purifiers/HEPA filters, dehumidifiers, floor mats, trampolines (including mini trampolines), suspension swings, hypoallergenic pillows/bedding, standard car seats, food and specialty diet products, and waterproof casts. These items are not considered Durable Medical Equipment under this policy and are not covered.

Procedures, supplies, or services intended to change or improve appearance without a significant physiologic benefit are excluded as cosmetic. The policy defines cosmetic procedures and cosmetic surgery and lists numerous specific exclusions, including but not limited to cervicoplasty, chemical peels/dermabrasion, augmentation mammoplasty, mastopexy, excision of excess skin (e.g., brachioplasty, abdominoplasty except panniculectomy), genioplasty, gynecomastia surgery, hair removal and hair transplants, inverted nipple surgery, laser treatment for acne/scars, liposuction, otoplasty, rhinoplasty, rhytidectomy (facelift), scar revision, sclerotherapy, subcutaneous filler injections, testicular prosthesis, and treatment of vitiligo. Drugs, supplies, and facility/surgeon charges related to cosmetic procedures are also excluded except where services are described as covered elsewhere in the policy.

Infertility‑related exclusions include a broad set of noncovered services and costs. The policy excludes coverage for surrogacy and gestational carrier costs (including drugs for implantation, embryo transfer, cryopreservation when not meeting the time limits described), use of donor eggs with a gestational carrier, costs for maternity care when the surrogate is not a member, donor recruitment and compensation, and procurement of frozen donor oocytes. The policy also excludes long‑term cryopreservation (>90 days) of sperm or embryos unless the member is in active infertility treatment (short‑term <90 days may be authorized for certain medical conditions). Additional exclusions include services for members who do not meet the definition of infertility, experimental infertility procedures, reversal of voluntary sterilization, and donor sperm/laboratory services when no diagnosed male‑factor infertility exists. Prior authorization is recommended for certain donor‑egg related medications when the member is not the sole recipient of the donor's eggs.

Services, programs, supplies or procedures provided in nonconventional settings are excluded. The policy requires services be performed by network providers unless an emergency or prior approval applies, and it specifically excludes services delivered in settings such as spas/resorts, educational, vocational or recreational settings, outward bound/wilderness/camp programs, and services performed outside the United States, even when provided by licensed clinicians. Examples of services that may be excluded when delivered in these settings include psychotherapy, ABA services, and nutritional counseling.

The policy enumerates several additional exclusions relevant to lodging, nonconventional settings, over‑the‑counter products, pediatric vision, and sterilization reversal. Lodging expenses are not covered even when related to receiving medical services. The policy excludes over‑the‑counter contraceptive agents, and lists pediatric vision exclusions such as non‑standard lenses, replacement for lost/stolen eyewear, plano lenses, and insurance of contact lenses. Reversal of voluntary sterilization and many sexual/erectile dysfunction treatments (except medically necessary services for organic conditions) are excluded. It also details gender‑related exclusions (e.g., cryopreservation/storage, voice modification surgery, reversal of genital surgery) and denies coverage for certain transportation modes. The policy further lists many miscellaneous noncovered items (personal emergency response systems, TENS units, waterproof casts, medical marijuana, weight‑loss programs, and other personal comfort or convenience charges).

The document provides explicit code lists identifying services that are non‑covered in each coverage context. For Medicaid, Integrity, and Commercial lines the policy enumerates specific HCPCS, CPT, ICD‑10 diagnosis, and ICD‑10‑PCS procedure codes and code ranges that are considered non‑covered. Examples in the Medicaid lists include multiple CPT ranges and HCPCS codes (see the coding tables), while the Integrity and Commercial sections present extensive G‑, K‑, L‑, P‑, Q‑, S‑ and other HCPCS groups and numerous ICD‑10‑PCS procedure code ranges designated as non‑covered.

A fragment of the policy explicitly lists numerous individual HCPCS and other procedure codes as non‑covered; this portion presents the codes themselves without linking exclusions to specific patient conditions. The presence of these enumerated codes means claims submitted with those codes in the respective plan contexts should be treated as non‑covered unless another policy or state regulation provides an exception.

The policy states that procedures performed solely to change or improve appearance without a significant physiologic benefit are considered cosmetic and not medically necessary. Multiple specific procedures are named to illustrate cosmetic exclusions, reinforcing that aesthetic‑only interventions and associated supplies are not payable under this policy unless an explicit medical‑necessity exception is documented elsewhere in the plan.

Reiterating the cosmetic standard, the policy specifies that services intended primarily to improve appearance without meaningful improvement in physiologic function are not medically necessary and therefore excluded. A wide range of surgeries and treatments (for example, breast augmentation/reduction where cosmetic, liposuction, facelifts, rhinoplasty, otoplasty, scar revision, tattooing/tattoo removal except nipple/areola reconstruction after mastectomy) are listed to clarify this stance.

Procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are treated as cosmetic and excluded, except where the policy identifies specific covered indications (for example treatment of gynecomastia or gender dysphoria in defined circumstances). The policy also clarifies exclusions for voice modification surgery and reversal of genital surgery.

The fragments list many service codes and code ranges as non‑covered without additional clinical qualifiers; in other words, the document treats these entries as explicit non‑covered services rather than framing them as conditional or patient‑specific denials. Providers should refer to the code lists to determine whether a billed code is on the non‑covered list for the relevant line of business.

Non-Covered Codes and Code Lists

Non-Covered ICD-10 Diagnosis Codes (Medicaid/Integrity/Commercial)ICD-10Not Covered

N46.01-N46.9	Male infertility and related codes
N52.9	Male erectile dysfunction, unspecified
N97.0-N97.9	Female infertility codes
Z00.8	Encounter for other general examination
Z01.20	Encounter for other screening for malignant neoplasm of cervix
Z01.21	Encounter for routine gynecological examination with cervical smear
Z02.1	Encounter for pre-employment examination
Z02.3	Encounter for examination for admission to educational institution
Z02.71	Encounter for drivers examination
Z02.79	Other administrative examinations

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Non-Covered ICD-10-PCS / Procedure Code Ranges (Medicaid/Integrity/Commercial)ICD-10Not Covered

08H005Z,08H105Z,08P00JZ,08P03JZ,08P10JZ,08P13JZ,08W00JZ,08W03JZ,08W10JZ,08W13JZ	Selected reproductive procedure procedure codes
090007Z-0902XZZ	Range of specified procedure codes
00W0X0Z–00WEXMZ,01WYX0Z–01WYXMZ,02WAX2Z–02WAXRZ,02WYX2Z–02WYXKZ,03WYX0Z–03WYXMZ,04WYX0Z–04WYXKZ,05WYX0Z–05WYXKZ,06WYX0Z–06WYXKZ	Broad operating/procedure code ranges
0C5W0Z0–0C5XXZ2,0C9W000–0C9XXZ2,0CBW0Z0–0CBX0Z2,0CCW0Z0–0CCXXZ2,0CCX0Z0–0CCX0Z2	Selected complex procedure ranges
0CWY07Z,0CX00ZZ–0CX1XZZ,0CX40ZZ–0CX4XZZ,0HDSXZZ,0HRSX7Z,0J010ZZ–0J0P3ZZ	Additional ICD-10-PCS codes listed in source
Multiple other extensive ICD-10-PCS ranges	Includes many ranges throughout sections 0,2,3,4,8 etc. as listed in source (e.g., 0UQ70ZZ–0UQ78ZZ,0US50ZZ–0US74ZZ,0UU507Z–0UU78KZ,0UY00Z0–0UY10Z2,0VQN0ZZ–0VQQ477,0W0007Z–0W0N4ZZ,0X0207Z–0X0H4ZZ,0Y0007Z–0Y0L4ZZ,2W31X9Z–2W31XYZ,3E00X3Z–3E00XMZ,8E0H300–8E0HXY9,BN0GZZZ etc.)

Non-Covered CPT Category I/II/III and Multirange Codes (Medicaid/Integrity/Commercial)CPTNot Covered

0010M,0012M,0013M	Specific new CPT codes (molecular/advanced)
0018U–0023U,0035U–0039U,0041U–0045U,0080U–0083U,00938,0081U,00938	Multianalyte molecular/pathology/other U codes and related
0141T,0142T,0143T,0203T–0225T,0232T–0233T,0239T,0242T–0244T,0249T,0254T,0255T,0260T,0263T–0288T,0291T–0294T,0299T–0317T,0329T–0341T,0343T–0358T,0375T–0504T,0482T–0536T	Extensive T-code ranges for procedures and tests
0035U–0039U,0041U–0044U,0081U	Selected U codes (unlisted/proprietary tests)
00938,15775,15776,15780–15783,15824–15839,15847,15876–15879,17340,17360,17380,17999	Surgical and skin lesion excision and related CPT codes
20983,20985,22505,22586,30430,31647–31651,31660–31661,32994,33340,33927–33929,34839,34841–34848,36416,36468–36469,43284,43881–43882,53860,54205,54250,54360,54400–54417,55400,55874,55970–55980,58321–58323,58750–58760,58970–58976,64550,64566,69090,69300,77061–77062	Selected surgical and diagnostic CPT codes
80300–80377,81175–81176,81230–81231,81238,81246–81249,81308–81313,81327–81335,81410–81417,81422,81425–81471,81521,81539–81552,81595,82205,82757,82777,83727,83987,84145,84431,86152–86153,86352,86910–86911,87001–87003,88000–89398	Extensive laboratory, genetic, and pathology CPT code ranges
90619,90630,90651,90653,90672,90682,90685–90689,90694,90697	Vaccine product CPT codes
90867–90869,90875–90880	Psychiatric procedure CPT codes
90901,91112,92145,92559,92605–92606,92618,92700,93050,93264,93702,93792–93793,93895,93980–93981,93998,95836,96570–96571,96900–96904,97169–97172,97533,97537,97810–97814,98943,98970–98972,99000–99027,99071,99075,99080,99172–99173,99421–99423,99441–99444,99446–99449,99450,99455–99456,99458,99461,99473,99490–99491,99495–99496	Additional varied CPT services including telehealth/remote and evaluation codes

Non-Covered HCPCS / C-Temporary / S / V / T / D Codes (Medicaid/Integrity/Commercial)HCPCSNot Covered

A0380,A0394,A0432,A0130	Selected ambulance and device supply codes
A4336,A4337,A4360,A4459,A4466,A4467,A4490,A4495,A4500,A4510,A4520,A4554,A4555,A4563,A4575,A4670,A6000,A6413,A6460,A6461,A9270,A9275,A9279,A9280–A9286,A9300,A9515,A9589,A9597–A9598	Various durable medical equipment, supplies, implants
B4105	Breast prosthesis-related HCPCS
C1734,C1749,C1823–C1841,C1889,C1890,C1982,C2596,C2645,C8931–C8937,C9014–C9016,C9024–C9034,C9042–C9046,C9067,C9141,C9365–C9369,C9406–C9408,C9462,C9466,C9729–C9731,C9734–C9738,C9748–C9758	Temporary C codes and implantable/biologic products
D0411,D5511–D5612,D5621–D5622,D6096,D6118–D6119,D7296–D7297,D7979,D8695,D9995–D9996	Dental-related codes
E0118,E0160–E0168,E0170–E0172,E0175,E0190,E0231–E0232,E0240–E0249,E0273–E0274,E0315,E0446,E0621,E0625,E0627–E0630,E0635–E0642,E0700,E0705,E0766,E0910–E0912,E0936,E0940,E0968,E1031,E1035–E1036,E1300	Durable medical equipment and orthotic/prosthetic codes
G0027,G0071,G0076–G0087,G0151–G0158,G0162–G0164,G0175–G0182,G0219,G0235,G0252,G0255,G0257,G0259,G0276,G0279,G0282,G0293–G0295,G0306–G0307,G0333,G0372,G0380–G0384,G0410–G0411,G0425–G0428,G0454,G0459,G0460,G0472–G0473,G0490–G0492,G0500–G0509,G0511–G0514,G1000–G1011,G2000–G2015,G2021–G2022,G2058–G2125,G8126–G8128,G8545–G8693,G9143,G9187,G9362–G9370,G9376–G9386,G9389–G9396,G9399,G9400–G9443,G9448–G9472,G9481–G9490,G9678–G9686,G9890–G9949,G9954–G9987	Many G-series and telehealth/remote monitoring/other service HCPCS not covered
K1001–K1005,L2006,L5969,L7600,L7902,L8033,L8605,L8608,L8696,L8698,L8701,L8702	K/L-series HCPCS (orthotics/prosthetics)
P2028–P2038,P9603–P9604,Q2033–Q2042,Q4112–Q4146,Q4149–Q4155,Q4162–Q4185,Q4188–Q4226,Q5108,Q5110–Q5115,Q9991–Q9995	Vaccine and product HCPCS and Q-codes
S0090,S0207–S0215,S0257,S0285,S0311,S0353–S0354,S0596,S0800,S0810,S1034–S1037,S2102–S2117,S2230,S2900,S3655,S3721,S3890,S4027,S5135–S5136,S5522,S8130–S8131,S8930,S8948,S8990,S9109–S9122,S9336,S9401,S9430,S9901,S9960–S9961	S-series codes and other non-covered supply/service codes

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Non-Covered Other / Misc Codes (Medicaid/Integrity/Commercial)mixedNot Covered

ICD-10 Procedure ranges: 00W0X0Z–00WEXMZ,01WYX0Z–01WYXMZ,...	Extensive ICD-10-PCS surgical/procedural ranges as listed in source
Numerous CPT Category II/III, F, and modifier codes	Includes many proprietary/unlisted CPT U/T codes and telehealth codes (examples: 0012M,0013M,0018U–0023U,0035U–0039U,0041U–0045U,0080U–0083U,0203T–0225T, etc.)
HCPCS examples: A0380,A4336,...,C1734,...,E0118,...,G0490–G0492,...,S4027,...,T1004, T4536–T4545,V codes etc.	Representative HCPCS, temporary C-codes, S-codes, T-codes, and V-codes indicated as non-covered across sections

Prior Authorization, Network & Documentation Requirements

Denial Risk

Investigational / Experimental Requirement

Investigational or experimental drugs, devices, or services that lack FDA approval, are investigational arms of clinical trials (Phase I/II or investigational arm of Phase III), or are delivered in connection with a non‑covered item/service are excluded. Exception: investigational/experimental services for cancer treatment may be covered per State regulation.

Denial Risk

Non‑Covered Codes — Integrity/Commercial

Extensive lists of CPT, HCPCS and other procedure codes are identified as non‑covered under the plan integrity/commercial listings. Claims submitted using any codes in these INTEGRITY / Commercial non‑covered lists may be denied.

Refer to the document sections titled 'Non‑Covered Services: INTEGRITY' and 'Non‑Covered Services: Commercial' for full code listings (G‑, K‑, L‑, P‑, Q‑, S‑ groups and many others).

DME: Medical Necessity Exceptions and Non-Coverage

inv-56: DME medical necessity exceptions and exclusions

DME items are not covered under these conditions unless documentation supports exception:

Abuse-related damage: Purchase, repair, or replacement when damage is due to enrollee abuse is not covered.

Stolen/destroyed items exception: If an item was stolen or destroyed, coverage for replacement requires: explanation of continuing medical necessity; explanation that the item was stolen or destroyed; and copy of police, fire department, or insurance report if applicable.

Warranty/rental exclusions: Repair of DME items not covered by Neighborhood; repair of DME items covered under provider's or manufacturer's warranty; and repair of rented DME items are not covered.

inv-57: DME non-coverage examples

Rental, Purchase and Replacement Rules for DME

Equipment / Situation	Policy Rule	Coverage
{"text":"Purchase, repair, or replacement of DME due to enrollee abuse","status":"not_covered"},{"text":"Excluded: purchase, repair, or replacement when damage results from enrollee abuse","status":""},{"text":"","status":""}
{"text":"Purchase, repair, or replacement of DME that has been stolen or destroyed","status":"neutral"},{"text":"May be covered only when documentation provided: explanation of continuing medical necessity; explanation item was stolen/destroyed; copy of police, fire department, or insurance report if applicable","status":""},{"text":"","status":""}
{"text":"Repair of DME items not covered by Neighborhood","status":"not_covered"},{"text":"Excluded: repairs of items identified as not covered by plan","status":""},{"text":"","status":""}
{"text":"Repair of DME items covered under provider's or manufacturer's warranty","status":"not_covered"},{"text":"Excluded: warranty-covered repairs are the responsibility of provider/manufacturer","status":""},{"text":"","status":""}
{"text":"Repair of rented DME items","status":"not_covered"},{"text":"Excluded: repair of rented DME is not covered by the plan","status":""},{"text":"","status":""}

HCPCS / CPT / Other Code	Context / Note	Coverage
{"text":"A4336","status":"not_covered"},{"text":"Listed in Non-Covered Services: INTEGRITY code list","status":""},{"text":"","status":"not_covered"}
{"text":"A4337","status":"not_covered"},{"text":"Listed in Non-Covered Services: INTEGRITY code list","status":""},{"text":"","status":"not_covered"}
{"text":"E0160 to E0163","status":"not_covered"},{"text":"Selected E- series DME HCPCS codes shown in INTEGRITY non-covered list","status":""},{"text":"","status":"not_covered"}
{"text":"E0231, E0232","status":"not_covered"},{"text":"Listed among non-covered DME HCPCS codes in Integrity section","status":""},{"text":"","status":"not_covered"}
{"text":"G0076 to G0087","status":"not_covered"},{"text":"Group of G-codes included in Integrity non-covered listing","status":""},{"text":"","status":"not_covered"}
{"text":"A9515","status":"not_covered"},{"text":"Included in INTEGRITY non-covered HCPCS listing","status":""},{"text":"","status":"not_covered"}
{"text":"B4105","status":"not_covered"},{"text":"Included in INTEGRITY non-covered code list (C-/B- series codes also listed)","status":""},{"text":"","status":"not_covered"}

Replacement (placeholder)

Replacement rules summaryReplacement intervals not specified in this fragment; see plan-specific DME replacement policies or contact provider services for replacement authorization rules.

Documentation Requirements for DME and Claims

Documentation Required

Required documentation for DME replacement after theft/destruction

When requesting replacement coverage after theft or destruction of DME, providers must submit: an explanation of continuing medical necessity for the item; an explanation that the item was stolen or destroyed; and a copy of any police, fire department, or insurance report, where applicable.

Documentation Required

Document clinical justification for orthotics/braces

When claiming medical necessity for orthotics or braces, document the clinical justification demonstrating why the orthotic/brace is required (policy notes many orthotic appliances and some braces are non‑covered).

Documentation Required

Maintain complete coding and documentation; anticipate audits

All claims are subject to coding and documentation guidelines and may be audited; documentation must support medical necessity and adherence to authorization and network rules.

Explicitly Not Covered Items

Repair and replacement rules for DME are constrained. The policy excludes repair of DME items not covered by Neighborhood, repair of items that are covered under the provider's or manufacturer's warranty, and repair of rented DME items. It also excludes purchase, repair, or replacement of DME that is the result of enrollee abuse. If an item was stolen or destroyed, replacement may be considered only when documentation is provided, including an explanation of continuing medical necessity, an explanation that the item was stolen or destroyed, and a copy of a police, fire department, or insurance report if applicable.

The policy confirms that non‑medical household equipment is not covered as DME. Items explicitly listed include dehumidifiers, trampolines (including mini trampolines), suspension swings, and waterproof casts. These items are classified as non‑covered and are not eligible for DME payment under the policy.

Dehumidifiers are listed among non‑DME household items excluded from coverage. The policy identifies dehumidifiers as an example of items that are not payable as DME or as covered services.

The policy repeats dehumidifiers in its non‑DME items list, reinforcing that these devices are considered household equipment and are not covered under the DME provisions.

Dehumidifiers are called out in the non‑covered items list; providers should not bill the plan expecting payment for dehumidifier equipment as DME.

Dehumidifiers appear repeatedly in the exclusions catalog as non‑covered household equipment and are not eligible for coverage under this policy.

Policy Background and Scope

This section of the policy provides background context noting that the document enumerates categories of services and supplies excluded from coverage. These categories include cosmetic procedures, alternative and complementary therapies, certain infertility services, DME and household items, personal comfort items, lodging, and investigational services, and are intended to clarify items and services that the plan will not pay for except where another policy or law provides an exception.

Key Definitions

Cosmetic Procedure / Cosmetic Surgery

DefinitionProcedures or services that change or improve appearance without significantly improving physiological function.

Cosmetic surgery (ASPS)Performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem (per American Society of Plastic Surgeons).

Coverage stanceExcept as described in covered services, any service, supply, or medication to change or improve appearance is not covered.

ExamplesIncludes cervicalplasty, chemical peels/dermabrasion, augmentation mammoplasty, abdominoplasty (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplants, inverted nipple surgery, laser treatments for acne/scars, liposuction, cosmetic prosthetic devices.

Surrogate / Gestational carrier

Surrogate definition

OpenPayer

Coverage Exclusions and Non‑Covered Services (Durable Medical Equipment and Other Exclusions)

Not Covered / Exclusions

Non-Covered Codes and Code Lists

Prior Authorization, Network & Documentation Requirements

DME: Medical Necessity Exceptions and Non-Coverage

Rental, Purchase and Replacement Rules for DME

Documentation Requirements for DME and Claims

Explicitly Not Covered Items

Policy Background and Scope

Key Definitions