CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non Covered Services Eff 2.15.2021 Through 7.14.2021

Defines services, items, therapies, procedures, and codes considered non-covered (exclusions) across Medicaid, INTEGRITY, and Commercial lines; includes DME, cosmetic, dental, infertility, alternative therapies, custodial care, travel, lodging, and many code lists by product. Not an all-inclusive list.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon Covered Services Eff 2.15.2021 Through 7.14.2021

Policy CodePolicy N/A

Change TypeFormat/content updatescosmetic language addedmedical marijuana added to exclusions

Effective DateFeb 28, 2017

Next Review Date

Key ActionReference the payer's non-covered code lists and follow network/prior authorization rules when submitting claims.

SourceLink

POLICY UPDATE CHANGES

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

02/22/21: Action = Policy Review Date recorded.

02/28/17: Action = Policy Effective Date

3Products listed (Medicaid/INTEGRITY/Commercial)

200+Non-covered CPT/HCPCS/other codes (approx.)

multipleExclusion categories

many

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ICD-10-PCS ranges listed

manyCPT codes listed

Policy Overview

This is Neighborhood Health Plan of Rhode Island's Non-Covered Services (exclusions) policy describing categories of services, items, therapies, procedures, and product-specific code lists that the plan considers non-covered. It applies to Medicaid, INTEGRITY, and Commercial products. The policy is informational and not an all-inclusive list of exclusions; plan-specific non-covered CPT, ICD-10 and HCPCS code lists are provided on product pages and within the document. Key scope items include exclusions for DME (purchase/repair/replacement in cases of abuse or when stolen/destroyed without required documentation), cosmetic services/surgeries, most dental services (except emergency/limited oral surgery), infertility/ART and donor/surrogacy costs, many alternative/holistic therapies, custodial care, transportation and lodging, and extensive product- and setting-specific code lists (ICD-10-PCS, CPT, HCPCS) that further define non-covered items.

Policy Metadata

Effective Date2017-02-28

Last Review2021-02-22

Next ReviewN/A

Policy NumberN/A

StatusCURRENT

Scope SummaryDefines services, items, therapies, procedures, and codes considered non-covered across Medicaid, INTEGRITY, and Commercial lines; includes DME, cosmetic, dental, infertility, alternative therapies, custodial care, travel, lodging, and many product-specific code lists.

General Non-Covered Services (Exclusions)

General Non-Covered Services

Services listed below are considered non-covered (exclusions) unless otherwise specified in covered services or state/federal law:

General exclusions

Investigational/Experimental: Investigational or experimental drugs/devices without FDA approval
Exception: investigational/experimental services covered for cancer treatment per State regulation
Clinical trial exclusions: Treatments that are subject to Phase I or Phase II clinical trials or investigational arm of Phase III clinical trials
Linked noncovered items: Services delivered in connection with or required by an item/service not covered

Product-Specific Non-Covered Services (INTEGRITY & Commercial)

Non-Covered Services - Integrity

The following ICD-10-PCS, CPT and HCPCS codes are designated Non-Covered Services under 'INTEGRITY'.

INTEGRITY code groups

ICD-10-PCS - Integrity: ICD-10 Procedure Codes listed for INTEGRITY (multiple ranges and individual codes, examples include 00W0X0Z to 00WEXMZ; 08H005Z; 08H105Z; 08P00JZ; 08P03JZ; 08P10JZ; many additional ranges)
Many ranges and individual ICD-10-PCS codes are enumerated (examples shown).
CPT - Integrity: CPT Codes listed for INTEGRITY (selected examples: 0012M, 0013M, 0018U to 0023U, 0035U to 0039U, 0041U to 0045U, 0203T to 0225T, many others)
CPT and HCPCS groups for INTEGRITY appear in document but specific CPT/HCPCS for INTEGRITY not always provided in this part.
HCPCS - Integrity:

Code Lists — Non-Covered Codes by Product & System

Unsupported block type: object

Billing, Documentation & Operational Requirements

Documentation Required

Documentation for stolen/destroyed DME

For DME items that were stolen or destroyed, submit documentation showing continuing medical necessity, an explanation that the item was stolen or destroyed, and a copy of the police, fire department, or insurance report if applicable.

Prior Authorization

Network / prior approval requirement for non-network services

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

Prior Authorization

Prior authorization recommended for certain donor egg medications

Prior authorization is recommended for drugs for anonymous or designated egg donors that are directly related to a stimulated assisted reproductive technology (ART) cycle, unless the member is the sole recipient of the donor's eggs.

Definitions

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

Cosmetic SurgeryDefined by the American Society of Plastic Surgeons: performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.

Background: this payment policy is informational only and is not a guarantee of reimbursement; product-specific non-covered code lists exist (Medicaid page, INTEGRITY page, Commercial page) and providers should reference those lists when billing. Claim payment remains subject to member benefits, eligibility, claims payment edit rules, coding and documentation guidelines, prior authorizations, provider contract agreements, and state and federal regulations.

Policy Revision Timeline

02/28/17added

02/28/17: Action = Policy Effective Date

02/15/21revised

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

02/22/21addedLatest

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon Covered Services Eff 2.15.2021 Through 7.14.2021

Policy CodePolicy N/A

Change TypeFormat/content updatescosmetic language addedmedical marijuana added to exclusions

Effective DateFeb 28, 2017

Next Review Date

Key ActionReference the payer's non-covered code lists and follow network/prior authorization rules when submitting claims.

SourceLink

On This Page

DME - abuse: DME: purchase/repair/replacement due to enrollee abuse

DME - stolen/destroyed: DME: purchase/repair/replacement of items stolen or destroyed unless documentation provided (continuing medical necessity; explanation item stolen/destroyed; police/fire/insurance report if applicable)

DME - repairs/warranty: Repair of DME items not covered by Neighborhood or covered under provider/manufacturer warranty

DME - rented item repair: Repair of a rented DME item

Non-DME home items: air conditioners, air cleaners/HEPA filters, dehumidifiers, floor mats, trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, food/products for specialty diets, waterproof casts

Cosmetic services and cosmetic surgery as defined: procedures to change/improve appearance without significant physiologic function improvement (extensive enumerated list included)

See separate cosmetic enumerations

Dental: orthodontia and all dental services except emergency dental and limited oral surgery

Home modifications: decks, permanent lifts affixed to home, enlarged doorways, accessibility mods (grab bars/ramps), fences, handrails, room additions/expansions, telephone alert systems/service

Infertility: home ovulation kits; services for couples where partner had previous sterilization; services intended to create a pregnancy; many ART/surrogacy/donor costs excluded; long-term (>90 days) sperm/embryo cryopreservation excluded unless member in active infertility treatment; short-term (<90 days) may be authorized for certain medical conditions

Alternative therapies: animal therapy, dance therapy, massage therapy, psychodrama, yoga, transcendental meditation, hypnotherapy (biofeedback exception: covered for urinary incontinence)

General exclusions - examples: General exclusions: academic performance testing, altered auditory feedback devices, chronic care management services, diagnostic tests to evaluate need for noncovered service, drugs/devices for sexual/erectile dysfunction (except medically necessary for organic condition), educational test/training programs, health club memberships, LASIK, medical alert ID bracelets, medical marijuana, personal emergency response systems, planned home births, respite care (except hospice), services outside U.S., sperm banking, vocational rehabilitation, wigs (except alopecia/cancer), and other listed items

Circumcision setting restriction: Circumcision: not covered if performed outside hospital, day surgery, or physician office

Custodial care, rest care, day care, non-skilled care in any facility not covered

Devices/appliances/prosthetics exclusions: dehumidifiers, sports safety devices, orthotic appliances that reshape, some braces including OTC orthotic braces, snoring reduction devices, electric hospital grade breast pump purchases

Eyewear/refractive surgery: Eyeglasses/lenses/frames: refractive eye surgery and deluxe frames not covered

Home births - doula: Home births: costs associated with doula services not covered

Homemaker services (non medical daily living tasks) not covered

Organ transplant exclusions: Human organ transplants: experimental/investigational transplant procedures excluded except required by law; donor-related services/supplies not directly related excluded; donor search expenses excluded; cord blood collection/preservation/future use excluded; donor expenses when recipient not a member excluded

Sterilization reversal: Reversal of voluntary sterilization: medical/surgical procedures for reversal not covered

Gender reassignment exclusions: Sexual reassignment/gender dysphoria: exclusions include cryopreservation/storage/thawing of reproductive tissue; procedures to enhance masculinity/femininity for aesthetic reasons excluded unless for gynecomastia and gender dysphoria; voice modification surgery; reversal of genital surgery

Transportation: chair car, wheelchair van, taxi and similar transportation excluded

Lodging: excluded even when related to receiving medical services

Network restrictions: services must be rendered by network providers unless emergency or prior approval received; services performed in nonconventional settings excluded even if licensed providers

OTC contraceptives: Over-the-counter contraceptive agents: not covered

Pediatric vision exclusions: materials not meeting standards, special lens designs/coatings beyond covered services, replacement of lost/stolen eyewear, non-prescription lenses, two pairs instead of bifocals, insurance of contact lenses

Personal care/comfort items: Items for personal care/comfort/ease (TV, telephone, beauty/barber, guest services) not covered; provider charges for missed appointments or copies of records not covered

Cosmetic Services — enumerated exclusions

Cosmetic procedures and surgeries excluded unless otherwise covered:

Enumerated cosmetic exclusions

Cervicoplasty (neck plastic surgery)
Chemical exfoliation/peels/dermabrasion: Chemical exfoliations, peels, abrasions, dermabrasions, planing for acne/scarring/wrinkling/sun damage
Breast anatomy correction: Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, congenital breast asymmetry
Cosmetic prosthetic devices
Cosmetic related charges: Drugs, biologics, hospital charges, pathology, radiology fees, and professional charges related to cosmetic surgery
Excision of excess skin/subcutaneous tissue (brachioplasty, abdominoplasty) except panniculectomy
Genioplasty
Gynecomastia surgery (including mastectomy/reduction mammoplasty)
Hair removal/transplants: Hair removal (electrolysis/epilation) and hair transplants
Inverted nipple surgery
Laser acne/scar treatment: Laser treatment for acne and acne scars
Liposuction/suction assisted lipectomy
Concurrent medically necessary procedure: Medically necessary procedures performed at same time as cosmetic procedure (excluded)
Osteoplasty (facial bone reduction)
Otoplasty
Skin tags/growth removal: Removal/destruction of skin tags; repeated cauterizations/electrofulguration for growths
Rhinoplasty/facelift: Rhinoplasty; rhytidectomy (facelift)
Scalp hair prostheses/wigs: Scalp hair prostheses made specifically for an individual or wig for alopecia or cancer treatment (note: exception for alopecia and cancer treatment mentioned elsewhere)
Scar revision regardless of symptoms
Sclerotherapy/spider veins: Sclerotherapy/treatment for spider veins
Cosmetic fillers: Subcutaneous injection of filling material (cosmetic fillers)
Tattooing/removal: Tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy)
Testicular prosthesis surgery
Vitiligo treatment: Treatment of vitiligo

HCPCS Codes listed for INTEGRITY (examples provided in INTEGRITY sections; HCPCS groups/references present)

Non-Covered Services - Commercial

The following ICD-10-PCS, CPT and HCPCS codes are designated Non-Covered Services for Commercial members.

Commercial code groups

ICD-10 Procedure Codes (Commercial) - examples/ranges: ICD-10 Procedure Codes (Commercial) including specific codes and ranges (examples: 09Q04ZZ, 09Q10ZZ to 09Q14ZZ, 09Q20ZZ to 09Q24ZZ, 09Q30ZZ to 09Q38ZZ, 09Q40ZZ to 09Q48ZZ, 09S00ZZ to 09S2XZZ; 0BW0X0Z to 0BW0XKZ; many additional ranges)
Ranges and specific codes shown as examples
CPT Codes (Commercial) - examples: Large list including molecular/genomic, procedures, and other CPTs: examples include 0012M, 0013M, 0018U to 0023U, 0035U to 0039U, 0041U to 0045U, 0080U to 0083U, 00938, 0203T to 0225T, 0232T, 0233T, 0239T, 0242T to 0244T, and many others (see document for full list)
HCPCS Codes (Commercial) - examples: HCPCS examples include A0130, A0380, A0432, A4336, A4337, A4360, A4459, A4466, A4467, A4490, A4495, A4500, A4510, A4520, A4554, A4555, A4563, A4575, A4670, A6000 and many C-codes and ranges

Specific Commercial Non-Covered Code Groups (additional lists)

Further enumerated Commercial non-covered codes across CPT, HCPCS and ICD-10-PCS in this part.

Specific Commercial non-covered code groups

CPT examples - Commercial additional lists: CPT examples: 55400, 55874, 55970, 55980, 56805, 57335, 58750, 58752, 58760, 64550, 64566, 69090, 69300, 77061-77062, 80300-80377, 81175-81176, 81230-81231, 81313, 81410-81417, 81422, 81425-81427, 81439-81440, 81455, 81465, 81470-81471, 81539, 81545, 81552, 81595, 82777, 83789, 83992, 84145, 86152-86153, 88000-88099, 89252, 89255-89256, 89259, 89262-89263, 89265-89279, 89282-89300, 89326-89330, 89332-89336, 89338-89398, 90619, 90630, 90672, 90682, 90685, 90689, 90694, 90697, 90875-90876, 90880, 90901, 91112, 92145, 92559, 92605-92606, 92618, 92700, 93050, 93264, 93702, 93792-93793, 93895, 93980, 93998, 95836, 96570-96571, 96900-96904, 97169-97172, 97533, 97537, 98970-98972, 99000-99002, 99024, 99026-99027, 99071, 99075-99080
Examples drawn from document lists
HCPCS examples - Commercial additional lists: HCPCS examples: G0235, G0252, G0255, G0257, G0259, G0260, G0276, G0279, G0282, G0293-0295, G0306-0307, G0333, G0372, G0380-G0384, G0410-G0411, G0425-G0427, G0428, G0454, G0459, G0460, G0490-G0492, G0500-G0509, G0511-G0514, G1000-G1011, G2000-G2015, G2058-G2083, G2086-G2125, G8126-G8128, G8545-G8628, G8629-G8693, G9376-G9386, and many others; plus S-/V-/T- codes listed in document
ICD-10-PCS examples - Commercial additional lists: ICD-10-PCS examples and ranges (many listed across sections) including codes such as 0GWSX0Z to 0GWSX3Z, 0HDSXZZ, 0J010ZZ to 0J0P3ZZ, 0W0207Z to 0W024ZZ, 0X0207Z to 0X0H4ZZ, 2W31X9Z, 3E00X3Z to 3E00XMZ, and many additional ranges

Billing Rule

Coding lists must be referenced

Plan‑specific listings of non‑covered CPT, ICD‑10 and HCPCS codes are provided on the product pages (Medicaid page 15, INTEGRITY page 18, Commercial page 23); providers should reference those lists when billing.

Denial Risk

Claims for listed non-covered codes will be denied

Do not bill the ICD‑10‑PCS, CPT, and HCPCS codes listed as non‑covered for the specified product (INTEGRITY or Commercial); claims submitted with those listed codes are at risk of denial.

Documentation Required

Reference the policy code lists when submitting claims

Providers must reference the payer's non‑covered code lists and ensure coding aligns with covered services to avoid billing denied services.

02/22/21: Action = Policy Review Date recorded.