Neighborhood Health Plan RI DME Coverage Update

Coverage Exclusions and Criteria

inv-01: Investigational or Experimental Services

Investigational/Experimental services

Investigational or Experimental: 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 delivered in connection with, or required by, an item or service not covered; exception: investigational or experimental services are covered for cancer treatment per State regulation.

inv-02: DME

DME exclusions

DME exclusions: Purchase, repair, or replacement of materials or equipment when the result of 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 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 the provider's or manufacturer's warranty; repair of a rented DME item.

Replacement for stolen or destroyed items may be allowed only with required documentation.

inv-03: Non-DME Items

Non-DME items not covered

Non-DME exclusions: Examples of non-covered home items include air conditioners (window or central); air cleansers, purifiers or HEPA filters; dehumidifiers; floor mats; trampolines and mini trampolines; suspension swings; hypoallergenic pillows/bedding; standard car seats; food and food products for specialty diets (e.g., gluten-free, casein-free); and waterproof casts.

Not an exhaustive list per policy.

inv-04: Cosmetic Services

Cosmetic services exclusions

Cosmetic exclusions: Services to change or improve appearance without significant physiologic benefit are excluded. Examples include cervicoplasty; chemical exfoliations/peels/dermabrasion; correction of variations in normal anatomy (augmentation mammoplasty, mastopexy, correction of congenital breast asymmetry); cosmetic prosthetic devices; drugs, biologics, hospital and professional charges related to cosmetic surgery; excision of excess skin or subcutaneous tissue (except panniculectomy); genioplasty; gynecomastia surgery; hair removal and hair transplants; inverted nipple surgery; laser treatment for acne and acne scars; liposuction/suction assisted lipectomy; otoplasty; rhinoplasty; rhytidectomy (facelift); scar revision; sclerotherapy for spider veins; subcutaneous fillers; tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy); testicular prosthesis surgery; treatment of vitiligo; osteoplasty; and other listed cosmetic procedures.

Also excludes related drugs, hospital and professional charges for cosmetic surgery.

inv-05: Dental

Dental exclusions

Dental exclusions: Orthodontia and all dental services are excluded except emergency dental services and limited oral surgery.

inv-06: Infertility

Infertility exclusions

Infertility exclusions: Home ovulation prediction kits; infertility treatment not covered for members who do not meet the definition of infertility; experimental infertility procedures; medical or surgical procedures for reversal of voluntary sterilization; costs of surrogacy (including drugs for implantation, embryo transfer, cryopreservation >90 days unless member in active treatment, use of donor egg and gestational carrier, maternity care if surrogate not a member); costs associated with donor recruitment and compensation; donor sperm and associated lab services in absence of diagnosed male factor infertility; procurement of frozen donor oocytes; services for conception following voluntary sterilization or unsuccessful reversal.

Short-term (<90 days) cryopreservation may be authorized for certain medical conditions; prior authorization is recommended for drugs for anonymous or designated egg donors when applicable.

inv-07: Alternative Therapies

Alternative therapies

Alternative therapies exclusions: Animal therapy; dance therapy; massage therapy; psychodrama; yoga; transcendental meditation and similar alternative therapies are not covered.

inv-08: Additional Coverage Exclusions

Additional general exclusions

General exclusions: Includes academic performance testing; altered auditory feedback devices; chronic care management services; diagnostic tests to evaluate need for a non-covered service; drugs or devices for sexual or erectile dysfunction; 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 or its territories; sperm banking; vocational rehabilitation; wigs (except for alopecia and cancer treatment); and other items listed in policy.

inv-09: Infertility Exclusions

Infertility-related services and procedures are not covered in specified circumstances.

Infertility Exclusions: Infertility treatment is not covered for members who do not meet the definition of infertility; experimental infertility procedures; medical or surgical procedures for reversal of voluntary sterilization; costs of surrogacy including drugs for implantation, embryo transfer, and cryopreservation (>90 days unless member in active treatment); use of donor egg and gestational carrier; maternity care if surrogate is not a member; long-term sperm or embryo cryopreservation (>90 days) unless in active treatment; donor recruitment and compensation; donor sperm and associated laboratory services absent diagnosed male factor infertility; procurement of frozen donor oocytes; drugs for anonymous or designated egg donors related to stimulated ART cycles unless the member is the sole recipient (prior authorization recommended).

Short-term (<90 days) cryopreservation may be authorized for certain medical conditions.

inv-10: Cosmetic Exclusions

Cosmetic services and procedures are not covered except where explicitly described as covered elsewhere.

Cosmetic Exclusions: Procedures performed to change or improve appearance without significant physiologic benefit are excluded, including cervicoplasty; chemical exfoliations/peels; augmentation mammoplasty; excision of excess skin (except panniculectomy); genioplasty; gynecomastia surgery; hair removal and transplants; inverted nipple surgery; laser acne treatments; liposuction; osteoplasty; otoplasty; repeated cauterizations; rhinoplasty; rhytidectomy; scalp hair prostheses or wigs except specified exceptions; scar revision; sclerotherapy for spider veins; subcutaneous fillers; tattooing/tattoo removal (except nipple/areola related to mastectomy); testicular prosthesis; treatment of vitiligo; and related drugs, hospital and professional charges for cosmetic surgery.

inv-11: General and Device Exclusions

Additional non-covered items and devices.

General and Device Exclusions: Examples include abortion (except specified exceptions), cord blood banking, critical care transport, diagnostic tests evaluating need for non-covered services, drugs/devices for sexual dysfunction, health club memberships, LASIK, medical marijuana, planned home births, private rooms (unless medically necessary), sperm banking, wigs (except alopecia and cancer), dehumidifiers, devices used specifically as safety items or to affect sports performance, orthotic appliances that straighten or re-shape a body part (e.g., foot orthotics, cranial banding), some types of braces including over-the-counter orthotic braces, devices/procedures to reduce snoring, and electric hospital grade breast pump purchases.

inv-12: Network and Setting Exclusions

Network and setting restrictions.

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

Examples of potentially excluded services in nonconventional settings include psychotherapy, ABA services, and nutritional counseling.

inv-13: Lodging and Custodial Care Exclusions

Other explicit exclusions

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

Custodial Care: Custodial care, rest care, day care, or non-skilled care in any facility (including convalescent homes, nursing homes, homes for the aged, halfway houses) is not covered.

This policy explicitly excludes a range of items and services from coverage. For DME, purchase, repair, or replacement that results from enrollee abuse is not covered; repairs of rented DME, items covered under a provider's or manufacturer's warranty, or repairs of DME items not covered by Neighborhood are also excluded. Non-DME household items such as air conditioners, HEPA/air purifiers, dehumidifiers, floor mats, trampolines, suspension swings, and waterproof casts are specifically listed as non-covered. Additional general exclusions (e.g., Lasik, medical marijuana, health club memberships, personal emergency response systems) further define services and supplies that are not eligible for payment.

Infertility- and surrogacy-related costs are excluded in multiple circumstances. The policy excludes coverage for infertility treatment when the member does not meet the definition of infertility or when procedures are experimental. Costs associated with surrogacy or use of a gestational carrier — including drugs for implantation/embryo transfer, cryopreservation beyond 90 days (unless the member is in active infertility treatment), maternity care when the surrogate is not a member, donor recruitment/compensation, procurement of frozen donor oocytes, and donor sperm/lab services absent diagnosed male-factor infertility — are not covered. Prior authorization is recommended for drugs for anonymous or designated egg donors when the member is not the sole recipient of the donor's eggs.

Services and procedures performed solely to change or improve appearance are considered cosmetic and are not covered. The policy defines a Cosmetic Procedure as one that modifies appearance without significantly improving physiological function; examples of excluded cosmetic services include but are not limited to cervicoplasty, chemical peels, augmentation mammoplasty, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplants, inverted nipple surgery, laser acne treatments, liposuction, rhinoplasty, rhytidectomy (facelift), scar revision, sclerotherapy for spider veins, subcutaneous fillers, tattooing/tattoo removal (except mastectomy areola), and testicular prosthesis. Related drugs, facility and professional charges for cosmetic surgery are also excluded.

Devices, appliances, and prosthetics intended primarily for comfort, safety, sports performance, or cosmetic purposes are not covered. Specifically listed non-covered items include dehumidifiers, devices used as safety items or to affect sports performance, orthotic appliances that reshape a body part (e.g., foot orthotics, cranial banding), some braces including over-the-counter orthotic braces, devices/procedures to reduce snoring, and electric hospital-grade breast pump purchases. Several standard home items (air conditioners, HEPA filters) are likewise excluded.

Services provided in nonconventional settings and lodging are excluded. Lodging is not covered even when related to receiving medical services. Services, programs, supplies or procedures delivered in locations such as spas/resorts, educational, vocational or recreational settings, wilderness programs, or services performed outside the United States and its territories are excluded unless prior approval is obtained or the service is an emergency.

The policy contains large enumerated lists of CPT, HCPCS, ICD-10 procedure, and diagnosis codes that are designated as non-covered across lines of business. These non-covered code groups apply to Medicaid, INTEGRITY, and Commercial products and should be referenced directly when validating coverage and billing; claims submitted with codes listed in these sections may be denied.

For Commercial members the document identifies an enumerated set of CPT, HCPCS, ICD-10-PCS and diagnosis codes that are Non-Covered Services. Providers should not bill Neighborhood for services using any of the codes listed in the Non-Covered Services: Commercial sections; claims with those codes are subject to denial.

Cosmetic services are defined by the policy as procedures that alter appearance without materially improving physiological function. Such services — including cosmetic surgery and related supplies, drugs, and professional/facility charges — are excluded unless specifically identified as covered elsewhere in the plan.

The cosmetic exclusion applies broadly and includes many examples to guide determinations of medical necessity: if the primary intent is aesthetic improvement rather than restoration of physiological function, the service is not covered. Related ancillary costs (e.g., hospital, pathology, radiology, surgeon and assistant surgeon fees) for cosmetic procedures are also excluded. Providers should document clinical indications when a procedure may have both functional and cosmetic components to support coverage when applicable.

Examples of cosmetic or other services that do not meet accepted standards or are excluded include: certain elective lens designs/coatings beyond covered services, procedures designed to alter body contours for aesthetic reasons (unless related to a covered condition such as gynecomastia or gender dysphoria per stated exceptions), and procedures considered cosmetic under the policy (e.g., tattooing/tattoo removal except post-mastectomy areola). These items are specifically listed to aid coding and claims review.

Non-Covered Codes and Coding Guidance

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

N46.01-N46.9	Male infertility related visits/diagnoses
N52.9	Erectile dysfunction, unspecified
N97.0-N97.9	Female infertility
Z00.8	Other general examination
Z01.20	Encounter for gynecological examination (general) without abnormal findings
Z01.21	Encounter for gynecological examination (general) with abnormal findings
Z01.3	Encounter for examination of breasts
Z02.1	Encounter for pre-employment examination
Z02.3	Encounter for examination for admission to educational institution
Z02.71	Encounter for examination for driving license

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Provider Responsibilities and Billing Rules

Prior Authorization

Prior authorization not applicable for listed non-covered codes

Do not request prior authorization for codes that are listed in the Non-Covered Services tables. Claims billed with CPT/HCPCS/ICD-10-PCS codes enumerated as Non-Covered for the member's product (Medicaid, INTEGRITY, Commercial) may be denied; providers should not submit PA requests for those codes.

Do not seek prior authorization for codes enumerated in the Non-Covered Services lists.
Claims submitted with listed non-covered codes are subject to denial on adjudication.

Denial Risk

Network provider requirement

Services must be furnished by Neighborhood network providers unless the service is an emergency or prior approval has been granted. Services, programs, supplies, or procedures provided in nonconventional settings (for example: spas/resorts, educational/vocational/recreational settings, outward bound/wilderness camps, services performed outside the United States or its territories) are excluded even if provided by licensed practitioners. Claims for non-network services without approved prior authorization are at risk for denial.

Medical Necessity Rules for DME

inv-70: DME Medical Necessity

DME excluded when not medically necessary or resulting from abuse/theft without documentation

DME not covered: Purchase, repair, or replacement when resulting from enrollee abuse; repair of items not covered by Neighborhood or items covered under provider's or manufacturer's warranty; repair of rented DME items. Replacement of stolen or destroyed DME may be considered only when documentation is provided (explanation of continuing medical necessity, explanation that item was stolen or destroyed, and police/fire/insurance report if applicable).

Claims resulting from abuse may be denied; follow documentation requirements for stolen/destroyed items.

inv-71: DME Non-covered Items

DME items that are non-covered

DME Noncoverage: Specified DME and device items are non-covered, including dehumidifiers; devices used specifically as safety items or to affect sports performance; orthotic appliances that reshape a body part (e.g., foot orthotics, 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, snore guards); and electric hospital-grade breast pump purchases. Additionally, providers should reference the Non-Covered Services code lists; HCPCS/CPT/ICD codes enumerated in those lists are not covered for the applicable lines of business.

Rental, Purchase and Specific Item Rules

Item	Rule
Rented DME
Repair of a rented DME item is not covered.
Replacement of DME resulting from enrollee abuse
Purchase, repair, or replacement of materials or equipment when the result of enrollee abuse is not covered.
Replacement of stolen or destroyed DME
Replacement allowed only when documentation provided: explanation of continuing medical necessity; explanation that item was stolen or destroyed; copy of police, fire department, or insurance report if applicable.
Repair of DME items covered under provider's or manufacturer's warranty
Repair of DME items covered under the provider's or manufacturer's warranty is not covered.
Repair of DME items not covered by Neighborhood
Repair of DME items not covered by Neighborhood is not covered.

Item	Coverage
Electric hospital grade breast pump (purchase)

Documentation and Audit Requirements

Documentation Required

Support replacement requests with police/insurance report and medical necessity

Provide an explanation of continuing medical necessity, an explanation that the DME was stolen or destroyed, and a copy of a police, fire department, or insurance report when submitting requests to replace DME lost to theft or destruction.

Note

Comfort/safety/sports/cosmetic devices are non‑covered

Devices and appliances primarily intended for comfort, safety, sports performance, or cosmetic purposes are non‑covered; documentation will not render these items coverable.

Documentation Required

Maintain documentation and be prepared for audit

Maintain complete documentation to support medical necessity, correct coding, and compliance with authorization and contract rules; be prepared to provide records for audit.

Examples and Lists of Not Covered Items

Repair, replacement, or purchase of DME that is the result of enrollee abuse is not covered and may be denied. Repair of DME covered under the provider's or manufacturer's warranty and repair of rented DME items are excluded. Non-DME home items such as air conditioners, dehumidifiers, trampolines, suspension swings, and waterproof casts are listed as not covered.

Dehumidifiers are specifically named as non-covered. The policy also lists other household and environmental control items (air conditioners, air purifiers/HEPA filters), and repeats dehumidifiers among excluded devices and appliances that are not eligible for coverage.

The policy enumerates a range of non-covered devices and supplies including Personal Emergency Response Systems (PERS), TENS units and other neuromuscular stimulators and related supplies, waterproof casts, and numerous HCPCS/ CPT/ICD codes listed in the non-covered code groups. These items and associated supplies are not eligible for reimbursement under the stated coverage lines.

The Non-Covered Services: Commercial lists include numerous specific code examples such as HCPCS A4336, A4337 and CPT codes including 33274 (and other CPT ranges and ICD-10-PCS codes). Codes shown in these Commercial non-covered sections are not covered and may result in claim denials if billed for Commercial members.

Key Definitions

Cosmetic Procedure

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

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

ExamplesCervicoplasty; chemical peels; augmentation mammoplasty; cosmetic prosthetic devices; hair removal/transplants; liposuction; excision of excess skin (except panniculectomy).

Cosmetic Surgery

Definition (ASPS)Cosmetic Surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

ScopeIncludes procedures to modify size, contour, or elevation of body structures; related hospital and professional charges for cosmetic surgery are excluded.

Background and Scope

This excerpt summarizes clinical and non-clinical categories of services excluded from coverage. It reiterates that cosmetic procedures (appearance-focused), experimental/investigational services (except specified cancer exceptions), infertility and surrogacy-related costs under defined circumstances, many DME and non-DME household items, alternative therapies, dental services (except emergencies/limited oral surgery), services provided outside the U.S., lodging, and services in nonconventional settings are not covered. Providers should refer to the detailed lists and code tables in the policy when determining coverage and preparing claims.

OpenPayer

Coverage exclusions and non-covered services (DME and related)