CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Policy Statement

Defines services, items, and circumstances that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Lists investigational/experimental exclusions, DME, cosmetic, dental, infertility, alternative therapies, custodial care, lodging, network restrictions, and numerous additional specific exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolicy Statement

Policy CodePolicy N/A

Change TypeUpdates to exclusions and externalized coding grid

Effective Date

Next Review Date

Key ActionProviders must follow the plan-specific external non-covered CPT/HCPCS/ICD-10/Modifier grids on the payer website and supply required documentation (including police/fire/insurance reports) for DME stolen/damaged claims when applicable.

POLICY UPDATE CHANGES

03/29/23: Added Concierge Services for all LOB, converted CPTs/HCPCs, ICD-10 and Modifiers to external link, added GC modifier to Commercial.

01/01/23: Annual Policy Review; additional codes added/removed from CPT/HCPC list.

02/15/21: Format changes and additional language added to cosmetic services for Medicaid and Integrity; medical marijuana added to exclusions.

02/28/17: Policy Effective Date recorded in history.

~100+Listed Exclusions (approximate count)

1External coding grid referenced

3LOBs specified (Medicaid excluding EFP, INTEGRITY, Commercial)

Coverage Summary

This policy documents Neighborhood Health Plan of Rhode Island's coverage exclusions and services that are considered non-covered and is informational regarding reimbursement and claim adjudication rules; it is not exhaustive and claim payments remain subject to plan benefit coverage, member eligibility, coding and documentation, authorization policies, provider contracts, and state and federal regulations.

Lines of business covered include Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial.

This policy lists non-covered/excluded services and references an external coding grid for plan-specific non-covered CPT, HCPCS, ICD-10 Diagnosis, and Modifier listings maintained on the payer website.

Policy metadata

SubjectNon-Covered Services / Coverage Exclusions

StatusCURRENT

LOBsMedicaid excluding EFP; INTEGRITY; Commercial

Approx. listed exclusions~100+

External coding gridYes — external non-covered CPT/HCPCS/ICD-10/Modifier grids referenced on payer website

Last review2023-03-29

Medical-Necessity Criteria and Exclusions

Investigational or Experimental Services

Drug or device that lacks FDA approval
Requested treatment that is the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials
Services which are delivered in connection with, or required by, an item or service not covered
Exception: Routine services associated with investigational or experimental services are covered for cancer treatment per State regulation

Durable Medical Equipment (DME) exclusions

Purchase, repair, or replacement of materials or equipment resulting from member abuse
Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed unless documentation provided (explanation of continuing medical necessity, explanation item was stolen or destroyed, copy of police/fire/insurance report if applicable)
Repair of Neighborhood non-covered DME items
Repair of DME items covered under provider's or manufacturer's warranty
Repair of a rented DME item

Circumcision

Circumcisions will not be covered if performed in any setting other than a hospital, day surgery, or a physician's office

Cosmetic Services and Procedures

Cosmetic procedures/surgery defined as services to change or improve appearance without significantly improving physiological function are not covered except as described in covered services.

Cervicoplasty (plastic surgery on the neck)
Chemical exfoliations, peels, abrasions, dermabrasions or planing for acne, scarring, wrinkling, sun damage or other conditions
Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, correction of congenital breast asymmetry
Cosmetic prosthetic devices
Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons, assistant surgeons, attending physicians and any incidental services related to cosmetic surgery

Dental Services

Orthodontia
All dental services other than emergency dental and limited oral surgery
Adult preventive and restorative services, treatments, and supplies (routine exams, X-rays, cleanings; restorative services like extractions, fillings, implants not covered)

Home Modifications (items for use in the home)

Decks
Lifts - permanent (affixed to home) are excluded; bed-to-chair lifts conditionally covered
Enlarged doorways
Environmental accessibility modifications such as grab bars and ramps
Fences
Handrails

Infertility Related Services

Home ovulation prediction kits
Services for couples in which one partner has had a previous sterilization procedure, with or without reversal
Any service or procedure intended to create a pregnancy
Infertility treatment not covered for members who do not meet the definition of Infertility
Experimental infertility procedures
Costs of surrogacy including drugs for implantation, embryo transfer, cryopreservation, maternity care for surrogate, and other associated surrogacy costs

Alternative / Complementary Therapies

Animal therapy of any type
Dance therapy
Massage therapy
Psychodrama
Yoga
Transcendental meditation
Alternative medicine services, supplies or procedures

Custodial Care

Custodial care, rest care, day care, or non-skilled care in any facility (convalescent homes, nursing homes, homes for the aged, halfway houses, or other residential facilities) is not covered

Devices, Appliances and Prosthetics - Selected Exclusions

Dehumidifiers
Devices used specifically as safety items or to affect performance in sports-related activities
Orthotic appliances that straighten or reshape a body part such as foot orthotics and cranial banding
Some types of braces, including over-the-counter orthotic braces
Devices and procedures intended to reduce snoring (e.g., laser-assisted uvulopalatoplasty, somnoplasty, and snore guards)
Electric hospital grade breast pump purchases

Eyeglasses, Lenses, Frames - Exclusions

Refractive eye surgery (including radial keratotomy) for conditions correctable by means other than surgery, contact lenses, or contact lens fittings
Deluxe frames are not covered

Human Organ Transplants - Exclusions

Experimental or investigational transplant procedures except those required by federal or state law
Transplants of the face and hand are considered experimental and are not covered
Services or supplies related to an excluded procedure
Services or supplies for a donor not directly related to the organ transplant
Services relating to collection, preservation and potential future use of umbilical cord blood
Donor related medical or other expenses of a transplant when the recipient is not a member

Reversal of Voluntary Sterilization

Medical or surgical procedures for reversal of voluntary sterilization are not covered

Sexual and Erectile Dysfunction Treatment

Services and treatment related to sexual and/or erectile dysfunctions are excluded, except medically necessary services for treatment related to an organic condition

Sexual Reassignment / Gender Dysphoria Treatment - Exclusions

Cryopreservation, storage and thawing of reproductive tissue (excluded)
Procedures designed to enhance masculinity or feminininity or to alter body contours for aesthetic reasons are considered cosmetic and excluded unless for treatment of gynecomastia and gender dysphoria
Voice modification surgery
Reversal of genital surgery

Lodging and Transportation

Lodging is not covered even when related to receiving any medical service
Transportation exclusions include chair car, wheelchair van, or taxi

Network Restrictions

Services must be rendered by network providers unless emergency or prior approval obtained.

Services performed in nonconventional settings are excluded even if provided by licensed providers (examples: spas/resorts; educational, vocational, or recreational settings; Outward Bound or wilderness programs)
Examples of services that may be excluded in nonconventional settings: psychotherapy, ABA services, nutritional counseling

Items for Personal Care, Comfort or Convenience

Charges when member chooses to remain inpatient beyond discharge hour for convenience
Supplies/equipment/services primarily for personal comfort (television, telephone, beauty/barber service, guest service)

Additional General Exclusions (selected list)

Academic performance testing
Adult respite care (exception: hospice)
Air conditioner (window or central)
Air cleansers, purifiers or HEPA filters
Altered Auditory Feedback Devices
Chronic Care Management Services

Coding

Coding referencemixed

See external grid

Plan-specific listings of non-covered CPT, HCPCS, ICD-10 Diagnosis, and Modifiers are maintained in external non-covered grids at https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/

Provider Actions

Documentation Required

DME stolen/damaged documentation requirement

For DME purchase/repair/replacement after theft or destruction, the provider must supply 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.

Prior Authorization

Non-network / out-of-network prior approval

Services must be rendered by network providers unless it is an emergency or prior approval has been received. Prior approval is required for non-network/out-of-network services to be considered.

Prior Authorization

Infertility-related drugs for egg donors

Prior authorization is recommended for drugs for anonymous or designated egg donors that are directly related to a stimulated Assisted Reproductive Technology (ART) cycle when the member is not the sole recipient of the donor's eggs; recommend obtaining prior authorization where applicable.

Billing Rule

External coding grid usage

Providers must follow the plan-specific external non-covered CPT/HCPCS/ICD-10 Diagnosis and Modifier grids maintained on the payer website for precise code-level exclusions; these external lists are the authoritative source for non-covered codes.

Denial Risk

Claims for excluded services will be denied

Claims for services listed as non-covered — including cosmetic procedures, the DME exclusions listed, alternative/complementary therapies, custodial care, lodging, transportation, and other listed exclusions — are subject to denial and audit.

Definitions

Cosmetic Procedure / Cosmetic Surgery: Procedures or services that change or improve appearance without significantly improving physiological function; Cosmetic Surgery is defined by the American Society of Plastic Surgeons as performed to reshape normal structures of the body in order to improve appearance and self-esteem.

Except as described in covered services, any service, supply, or medication to change or improve appearance is not covered (examples include cervicoplasty, chemical peels/exfoliations, augmentation mammoplasty, cosmetic prosthetic devices, excision of excess skin such as brachioplasty or abdominoplasty except panniculectomy, gynecomastia surgery, hair removal or transplants, laser treatment for acne, liposuction, rhinoplasty, rhytidectomy, scar revision, sclerotherapy, subcutaneous filling injections, tattooing/tattoo removal except nipple/areola related to mastectomy, and treatment of vitiligo).

Medicare Determinations

Number/Type	Name	Effective Date
see reference / NCD
Routine services associated with investigational or experimental services for cancer treatment

Revision History

2017-02-28effective

Policy Effective Date recorded in history (02/28/17).

2021-02-15material_revision

Format changes and additional language added to cosmetic services for Medicaid and Integrity; medical marijuana added to exclusions (material change).

2023-01-01annual_review

Annual Policy Review; additional codes added/removed from CPT/HCPC list (coding grid updates).

2023-03-29administrative_updateLatest

Added Concierge Services for all lines of business; converted CPTs/HCPCs, ICD-10 and Modifiers to external link; added GC modifier to Commercial (administrative/coding list management change; externalized code lists).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolicy Statement

Policy CodePolicy N/A

Change TypeUpdates to exclusions and externalized coding grid

Effective Date

Next Review Date

On This Page

Excision of excess skin or subcutaneous tissue including brachioplasty or abdominoplasty (except panniculectomy)

Gynecomastia surgery including mastectomy and reduction mammoplasty

Hair removal (including electrolysis epilation)

Inverted nipple surgery

Laser treatment for acne and acne scars

Liposuction / suction assisted lipectomy

Medically necessary procedures performed at the same time as a cosmetic procedure (excluded)

Osteoplasty (facial bone reduction)

Otoplasty (ear plastic surgery)

Removal or destruction of skin tags

Repeated cauterizations or electrofulguration methods used to remove growths on the skin

Rhinoplasty (nose plastic surgery)

Rhytidectomy (facelift)

Scalp hair prostheses or wig made specifically for an individual (exception: alopecia and cancer treatment noted elsewhere but listed as excluded earlier)

Scar revision, regardless of symptoms

Sclerotherapy / treatment for spider veins

Subcutaneous injection of filling material

Tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy)

Testicular prosthesis surgery

Treatment of vitiligo

Room additions and room expansions

Telephone alert systems

Telephone service in the home

Long-term (>90 days) sperm or embryo cryopreservation unless member is in active infertility treatment (short-term <90 days may be authorized for certain medical conditions)

Costs associated with donor recruitment and compensation

Infertility services necessary for conception as a result of voluntary sterilization or following unsuccessful reversal

Donor sperm and associated laboratory services in absence of diagnosed male factor infertility in the partner

Procurement of frozen donor oocytes

Drugs for anonymous or designated egg donors related to stimulated ART cycles, unless member is sole recipient of donor's eggs (prior authorization recommended)

Biofeedback is not covered except for treatment of urinary incontinence

Electro sleep therapy

Intravenous histamine therapy

Concierge services fee or retainer

Diagnostic tests to evaluate the need for a non-covered service

Drugs or devices used to treat sexual or erectile dysfunction (general exclusion)

Educational test and training programs

Food and food products for use in specialty diets (including gluten free, casein free)

Health club memberships

Hypoallergenic pillows/bedding

Personal emergency response systems

Sperm banking (subject to infertility section exceptions)

Trampolines, mini trampolines

Vocational rehabilitation

Wigs (exception: alopecia and cancer treatment)

Any provider charges for missing an appointment

Charges for copies of member records, charts or X-rays or forwarding/mailing costs

Office infection control charges

Weight loss programs and clinics - inpatient and outpatient

Services, supplies, or medications required by a third party which are not otherwise medically necessary

Services for which no charge would be made if member had no health plan

Services provided to a non-member except as described in covered services

Care covered under Federal, State or local legislation (e.g., workers' comp, no-fault auto)

Health services while on active military duty

Any additional fee a provider may charge