CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage Exclusions and Non‑Covered Services

Defines items, services, and circumstances that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business; affects providers submitting claims and members requesting services.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage Exclusions and Non‑Covered Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm DME and procedure codes are not listed as non-covered before billing and provide required documentation for replacement of stolen or destroyed DME.

SourceLink

Medicaid; INTEGRITY; Commerciallines of business

~700+non-covered codes total

Requiredreplacement documentation

~20+explicit exclusions

Coverage Exclusions and Criteria

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Services and items expressly not covered include the following categories and specific items:

Investigational/Experimental: Drugs or devices that lack FDA approval and treatments that are the subject of Phase I or II trials (or the investigational arm of Phase III) are excluded; services delivered in connection with non-covered items may be denied. Exception: investigational or experimental services for cancer treatment may be covered per state regulation.

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

Non‑DME household/environmental items: Common household or environmental items are excluded, including air conditioners (window or central), air cleansers/purifiers/HEPA filters, dehumidifiers, floor mats, trampolines/mini-trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, waterproof casts, and food products used for specialty diets.

Cosmetic services: Procedures, supplies, and related services intended to change or improve appearance without significant physiologic benefit are excluded. Examples include cervicoplasty, chemical peels/exfoliations, augmentation mammoplasty and related breast procedures, cosmetic prosthetics, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal and hair transplants, inverted nipple surgery, laser treatments for acne/scars, liposuction, otoplasty, rhinoplasty, facelifts (rhytidectomy), scar revision, subcutaneous injection of filling material, tattooing/tattoo removal (except nipple/areola related to mastectomy), testicular prosthesis surgery, treatment of vitiligo, and related drugs, facility, and surgeon charges.

Dental: Orthodontia and all dental services other than emergency dental care and limited oral surgery are excluded.

Home modifications and structural items: Permanent home modifications and structural items are excluded (examples: decks; permanent lifts affixed to the home; enlarged doorways; environmental accessibility modifications such as grab bars and ramps; fences; handrails; room additions/expansions; telephone alert systems/services). (Note: bed-to-chair lifts are conditionally covered per policy footnote.)

Infertility-related exclusions (general): Numerous infertility-related items and services are excluded including home ovulation prediction kits and many assisted reproduction services; infertility treatment is not covered for members who do not meet the definition of infertility; experimental infertility procedures; costs of surrogacy/gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation, use of donor egg, maternity care when surrogate is not a member); long-term (>90 days) sperm or embryo cryopreservation except when member is in active infertility treatment (short-term <90 days may be authorized for certain medical conditions); donor recruitment/compensation; donor sperm related lab services absent diagnosed male factor infertility; procurement of frozen donor oocytes; and drugs for anonymous or designated egg donors related to a stimulated ART cycle (prior authorization recommended unless member is sole recipient).

Alternative and complementary therapies: Animal therapy, dance therapy, massage therapy, psychodrama, yoga, transcendental meditation, and similar alternative therapies are excluded.

Items for personal care, comfort or convenience: Supplies, equipment, services, or charges primarily for personal comfort or convenience are excluded, for example television, telephone, beauty/barber services, guest services, private rooms (unless medically necessary), and charges when a member remains inpatient for convenience beyond the discharge hour.

Other general exclusions: Additional explicit exclusions include but are not limited to 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; educational testing/training programs; health club memberships; LASIK; medical marijuana; personal emergency response systems; planned home births (see separate home birth exclusions); respite care except hospice; services provided outside the U.S.; sperm banking; vocational rehabilitation; wigs except for alopecia and cancer treatment; transportation (chair car, wheelchair van, taxi); cord blood banking; critical care transport; and thermogenic or electro sleep therapies.

Infertility - Not Covered Conditions

Not covered when ANY of the following infertility-related conditions apply:

Infertility-related exclusions: Members who do not meet the definition of infertility; experimental infertility procedures; medical or surgical reversal of voluntary sterilization and services necessary for conception after voluntary sterilization or failed reversal; costs associated with surrogacy/gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation of embryos, use of donor egg, maternity care if the surrogate is not a member); long-term (>90 days) sperm or embryo cryopreservation unless member is in active infertility treatment (note: short-term <90 days may be authorized for certain medical conditions); donor recruitment and compensation; donor sperm and associated laboratory services when no diagnosed male factor infertility; procurement of frozen donor oocytes; and drugs for anonymous or designated egg donors related to a stimulated ART cycle (prior authorization recommended unless the member is the sole recipient of the donor's eggs).

Cosmetic Services - Not Covered

Not covered: cosmetic procedures and services that change appearance without significant physiologic benefit.

Cosmetic exclusions: Procedures, supplies, and associated services intended primarily to change or improve appearance without significant physiologic benefit are excluded. Specific non-covered cosmetic services include cervicoplasty; chemical exfoliations/peels/dermabrasion; correction of normal anatomic variations including augmentation mammoplasty and mastopexy; cosmetic prosthetic devices; related drugs, facility, and professional charges; excision of excess skin or subcutaneous tissue (except panniculectomy); genioplasty; gynecomastia surgery; hair removal (including electrolysis) and hair transplants; inverted nipple surgery; laser treatment for acne and acne scars; liposuction/suction-assisted lipectomy; osteoplasty (facial bone reduction); otoplasty; removal/destruction of skin tags; repeated cauterization/electrofulguration for skin growths; rhinoplasty; rhytidectomy (facelift); scalp hair prostheses or wigs (subject to exceptions for alopecia/cancer); scar revision; sclerotherapy for spider veins; subcutaneous injection of filling material; tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy); testicular prosthesis surgery; and treatment of vitiligo.

Miscellaneous Exclusions

Other explicit non-covered items and categories include:

General exclusions: Abortion services except limited statutory exceptions; academic performance testing; altered auditory feedback devices; cord blood banking; critical care transport; diagnostic tests to evaluate need for non-covered services; drugs/devices for sexual or erectile dysfunction; educational testing and training programs; electro sleep therapy; health club memberships; intravenous histamine therapy; LASIK; medical marijuana; planned home births; private rooms (unless medically necessary); sperm banking; thermogenic therapy; vocational rehabilitation; wigs (except alopecia and cancer treatment); and similar items.

Devices, appliances and prosthetics (non-covered): Dehumidifiers; devices used specifically as safety items or to affect sports-related performance; orthotic appliances that straighten or reshape a body part (for example foot orthotics and cranial banding); some types of braces including over-the-counter orthotic braces; devices and procedures intended to reduce snoring (including laser-assisted uvulopalatoplasty, somnoplasty, and snore guards); and electric hospital-grade breast pump purchases are not covered.

Personal care/comfort items: Supplies and services primarily for personal comfort or convenience are excluded (examples: television, telephone, beauty/barber services, guest services), and charges when a member remains inpatient for convenience beyond discharge hour.

Custodial Care - Not Covered

Custodial care:

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

Human Organ Transplants - Not Covered

Human organ transplant related exclusions:

Transplant exclusions: Experimental or investigational transplant procedures (except those required by federal or state law) are not covered; services or supplies related to excluded procedures; services or supplies for a donor not directly related to the transplant; expenses for donor searches; services relating to collection, preservation, and potential future use of umbilical cord blood; and donor-related medical or other expenses when the transplant recipient is not a member are not covered.

Home Births - Not Covered

Home birth related exclusions:

Home birth exclusions: Costs associated with services provided by a doula are not covered.

Non‑DME household or environmental items are expressly excluded from coverage. Examples include dehumidifiers, trampolines (including mini trampolines), suspension swings, waterproof casts, as well as other home air/cleaning equipment listed (e.g., air conditioners, air purifiers/HEPA filters, floor mats, hypoallergenic bedding and standard car seats).

This policy contains an extensive set of explicit exclusions across multiple categories. Key exclusions include: infertility-related services and costs (see detailed infertility exclusions), cosmetic and elective procedures and related supplies, investigational or experimental services and devices, specified devices/appliances/prosthetics (for example dehumidifiers, some orthotics and OTC braces, devices to reduce snoring, electric hospital-grade breast pump purchases), cord blood and sperm banking, donor-related transplant expenses, and numerous other items and services enumerated in the document.

Lodging expenses are not covered under any circumstance, including when lodging is incurred in connection with receiving a medical service.

Services provided in nonconventional settings are excluded. Examples of excluded settings include spas/resorts, educational, vocational, or recreational settings, outward‑bound/wilderness/camp/ranch programs, and services performed outside the United States and its territories; services performed in these settings may be denied even if provided by licensed clinicians.

Over‑the‑counter contraceptive agents are not covered.

Pediatric vision care exclusions include services and materials that do not meet accepted optometric practice standards. Specific examples include special lens designs or coatings not described as covered, replacement of lost or stolen eyewear, non‑prescription (Plano) lenses, and providing two pairs of eyeglasses in lieu of bifocals; insurance of contact lenses is also excluded.

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

Services and treatments related to sexual and/or erectile dysfunction are excluded unless they are medically necessary for treatment of an identified organic condition; otherwise such services are not covered.

Exclusions related to sexual reassignment and gender dysphoria treatment include cryopreservation, storage, and thawing of reproductive tissue, procedures intended to alter body contours or enhance masculinity/femininity for aesthetic reasons (unless specifically allowed for gynecomastia or gender dysphoria), voice modification surgery, and reversal of prior genital surgery.

Transportation services are excluded. This includes transportation by chair car, wheelchair van, taxi, and similar conveyances.

Additional general exclusions include charges such as provider missed appointment fees, fees for copies of member records or forwarding of records, chronic care management services, personal convenience or comfort items and services, TENS and other neuromuscular stimulators and related supplies, waterproof casts, weight‑loss program charges, and services or supplies required by a third party that are not medically necessary.

Services and items enumerated in the document sections titled 'Non‑Covered Services: INTEGRITY' and 'Non‑Covered Services: Commercial' are excluded from coverage. Those sections provide extensive CPT, HCPCS, ICD‑10 and modifier lists that identify specific procedure and supply codes as non‑covered.

The policy explicitly identifies numerous CPT, HCPCS, S/T/V and related code ranges as non‑covered for commercial product lines. Providers must reference the listed code tables in the document when billing commercial members, as those codes are designated non‑covered for commercial plans.

Procedures and services that change or improve appearance without producing a significant physiologic benefit are considered cosmetic and are not medically necessary. The policy lists many examples of cosmetic procedures (surgical and non‑surgical) that are excluded from coverage.

The policy defines cosmetic procedures as those performed to change or improve appearance without significantly improving physiological function. Cosmetic surgery is described per the American Society of Plastic Surgeons as reshaping normal structures to improve appearance and self‑esteem; such procedures and related supplies are excluded except where coverage is explicitly described.

The document lists diagnosis codes referenced in exclusions for commercial coverage (examples include F64.1, F64.2, F64.8, F64.9, L70.x, L73.0, L80, N52.9 and various Z‑codes). These diagnosis codes appear in the 'Non‑Covered Services: Commercial' lists and indicate excluded clinical indications when billing commercial plans.

Non-Covered Codes and Code Lists

Non-Covered CPT Codes (Medicaid & Commercial consolidated)CPTNot Covered

0005U
0007U
0008U
0009U
0010U
0011M
0011U
0012M
0012U
0013M

1–10 of 182

1/19

Non-Covered HCPCS (Medicaid & Commercial consolidated)HCPCSNot Covered

A0170
A0380
A4244
A4245
A4246
A4247
A4248
A4252
A4257
A4283

1–10 of 73

1/8

Additional Non-Covered Codes (mixed systems)mixedNot Covered

C1734
C1749
C1761
C1823
C1824
C1831
C1839
C1841
C1889
C1890

1–10 of 37

1/4

Non-Covered Modifiers (partial list)ModifierNot Covered

EY
GC
GL
HU
HV
HW
HX
HY
HZ
J1

1–10 of 25

1/3

Commercial Non-Covered CPT Codes (consolidated key ranges & single codes)CPTNot Covered

938
11200
11201
15771
15772
15775
15776
15780
15781
15782

1–10 of 264

1/27

Commercial Non-Covered HCPCS & Other (consolidated)HCPCSNot Covered

B4105
C1831
C1839
C1841
C1889
C1890
C1982
C2596
C2645
C8931

1–10 of 99

1/10

Provider Responsibilities and Prior Authorization

Prior Authorization

Applicability and authorizations

This policy applies to Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines of business. Providers must verify member benefits, eligibility, and obtain any required authorizations prior to providing services.

Applicability: Medicaid (excl. EFP), INTEGRITY, Commercial
Verify member coverage and eligibility before scheduling services
Obtain prior authorization when required by plan rules

Billing Rule

Prior authorization not applicable for non-covered codes

The codes listed in the documented "Non-Covered Services" sections for Commercial and INTEGRITY are identified as non-covered — these codes do not require prior authorization because they are non-covered. Providers should not submit prior authorization requests for services that are non-covered for the member type.

Non-covered codes (Commercial and INTEGRITY) are listed in the Document History / Non-Covered Services lists
Do not request prior authorization for codes explicitly listed as non-covered for the member's plan

Denial Risk

DME replacement/repair triggers

Repair, replacement, or purchase of DME resulting from enrollee abuse will be denied. Replacement or repair of DME items that were stolen or destroyed will be denied unless the request includes supporting documentation: explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and a copy of a police/fire/insurance report if applicable. Repairs covered by manufacturer or provider warranty, repairs of rented DME, and repairs not covered by Neighborhood are excluded.

Denied when DME damage is due to enrollee abuse
For stolen/destroyed DME, submit: explanation of continuing medical necessity; explanation of theft/destruction; copy of police/fire/insurance report if applicable
Repairs under warranty and repairs of rented DME are not covered

Denial Risk

Billing non-covered CPT/HCPCS codes

Claims submitted using CPT/HCPCS codes listed in the Non-Covered Services sections for Commercial or INTEGRITY will be considered non-covered and may be denied. Providers must avoid billing these codes to Neighborhood for affected member types and should verify allowable codes before submission.

Billing Non-Covered CPT/HCPCS codes will trigger non-coverage/denial
Verify allowable codes for the member's product prior to billing
Do not submit claims for codes listed in the Non-Covered Services lists

Denial Risk

Denial risk for billed codes

Claims for codes listed as non-covered for a given member type carry denial risk. Submissions for those codes may be denied; payments are subject to eligibility, coding and documentation rules, authorization policies, and provider contract terms. Providers should confirm network status and prior approval requirements to avoid denial.

Claims subject to member eligibility, coding/documentation, edits, and authorization policies
Non-covered code submissions may be denied
Services from non-network providers without prior approval (except emergencies) may be denied

Note

Reference document history and non-covered code lists

Refer to the Document History and the Non-Covered Services lists included in this policy for the most current code changes and additions. These lists identify codes added or removed over time; providers must reference the current allowable and non-covered code lists before ordering or billing services.

Document History lists code additions/changes (see Document History sections)
Use current Non-Covered Services lists for Commercial and INTEGRITY when validating billing

Documentation Required

Documentation of non-covered CPT codes

The policy includes documented lists that explicitly identify numerous CPT and HCPCS codes as non-covered for Commercial members and for INTEGRITY. Providers should not bill these non-covered CPT/HCPCS codes to Commercial or INTEGRITY members; confirm member product and allowed codes prior to claim submission.

Commercial non-covered CPT and HCPCS codes are listed in the Non-Covered Services: Commercial sections
INTEGRITY non-covered codes are listed in the Non-Covered Services: INTEGRITY section
Do not bill listed non-covered CPT/HCPCS codes to affected member types

DME Medical Necessity and Exceptions

DME replacement exception

DME repairs and replacements are excluded except when:

Allowed replacement with documentation: Replacement of DME that has been stolen or destroyed may be considered only when documentation is provided that includes: an explanation of continuing medical necessity for the item; an explanation that the item was stolen or destroyed; and a copy of a police, fire department, or insurance report if applicable.

DME - Not Covered Equipment

DME exclusions (specific equipment): Certain devices, appliances and prosthetics are explicitly not covered as DME, including dehumidifiers; devices used specifically as safety items or to affect sports performance; orthotic appliances that re-shape a body part (for example foot orthotics and cranial banding); some types of braces including over-the-counter orthotic braces; devices and procedures intended to reduce snoring (for example laser-assisted uvulopalatoplasty, somnoplasty, and snore guards); electric hospital-grade breast pump purchases; and listed non-DME household items (e.g., air cleaners/purifiers, suspension swings, waterproof casts) when billed as medical DME.

DME Rental and Purchase

Item	Rule / Guidance	Coverage Status
Rented DME
Repairs of rented DME items are excluded (repair of a rented DME item).
Replacement of stolen or destroyed rented DME may be considered only when documentation is provided: explanation of continuing medical necessity; explanation that the item was stolen or destroyed; copy of police/fire/insurance report if applicable.

Required Documentation and Billing Guidance

Documentation Required

Required documentation for DME replacement after theft/destruction

When requesting replacement for stolen or destroyed DME, include 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.

Explanation of continuing medical necessity
Explanation that the item was stolen or destroyed
Copy of police, fire department, or insurance report (if applicable)

Note

Explicitly not covered DME devices and appliances

Certain devices and appliances are explicitly not covered, including dehumidifiers, some orthotic appliances (including over-the-counter orthotic braces), devices to reduce snoring, and electric hospital-grade breast pump purchases; do not bill these as covered DME.

Dehumidifiers
Some orthotic appliances (e.g., foot orthotics, cranial banding) and OTC orthotic braces
Devices/procedures intended to reduce snoring (e.g., snore guards, laser-assisted uvulopalatoplasty, somnoplasty)
Electric hospital-grade breast pump purchases

Documentation Required

Consult plan-specific non-covered code lists and coding guidelines

Consult the plan‑specific non-covered CPT, ICD-10, and HCPCS code lists provided in the document and follow coding and documentation guidelines for claims to avoid billing errors and denials.

Billing Rule

Confirm DME codes are not on non-covered lists before billing

Confirm that any DME-related HCPCS/CPT codes you intend to bill are not included in the non-covered lists for the applicable product line; codes appearing in the non-covered lists will be denied.

Explicitly Not Covered Items

Purchase, repair, or replacement of DME that results from enrollee abuse is not covered. Repair of DME items that are not covered by Neighborhood, repairs covered under the provider's or manufacturer's warranty, and repair of rented DME items are also excluded. Replacement of stolen or destroyed DME is not covered unless the provider supplies documentation 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 when applicable.

Certain devices and appliances commonly encountered in DME and device billing are specifically listed as not covered. These include dehumidifiers, various over‑the‑counter orthotic braces and some types of braces, foot orthotics and cranial banding, devices used as safety or to affect sports performance, devices and procedures intended to reduce snoring, and electric hospital‑grade breast pump purchases.

The policy identifies specific HCPCS DME codes and broad code ranges that are non‑covered for commercial members. Many E‑, K‑, L‑, Q‑ and related HCPCS code blocks appear in the 'Non‑Covered Services: Commercial' lists and should not be billed for commercial product lines.

Policy Background

Background: This document lists services and items considered non‑covered by the payer across Medicaid (excluding EFP), INTEGRITY, and Commercial lines. It includes investigational/experimental services, detailed DME exclusions (including exclusions for abuse, warranty‑covered repairs, and rented items), cosmetic and dental exclusions, infertility limitations, and plan‑specific non‑covered code listings that affect billing and claims adjudication.

Key Definitions

Cosmetic Procedure and related terms

DefinitionCosmetic Procedure: Procedures or services that change or improve appearance without significantly improving physiological function.

Cosmetic Surgery (ASPS)Defined by the American Society of Plastic Surgeons as procedures to reshape normal structures of the body to improve appearance and self‑esteem.

Scope of exclusionExcept as described in covered services, any service, supply or medication to change or improve appearance is not covered.

Examples (not covered)Includes cervicoplasty; chemical peels/dermabrasion; augmentation mammoplasty and mastopexy; cosmetic prosthetic devices; excision of excess skin (except panniculectomy); genioplasty; gynecomastia surgery; hair removal and transplants; inverted nipple surgery; laser acne treatment; liposuction; osteoplasty.

Surrogate / Gestational carrier — definition and notes

Surrogate (general)A surrogate is a person who carries and delivers a child for another either through artificial insemination or surgical implantation of an embryo.

Costs excludedThe costs of surrogacy (all costs incurred by a fertile woman to achieve pregnancy as a surrogate/gestational carrier) are not covered, including drugs for implantation, embryo transfer, cryopreservation, donor egg use, maternity care if surrogate not a member, donor recruitment/compensation.

Related infertility exclusionsInfertility treatment is not covered for members who do not meet the definition of infertility; experimental procedures and related donor/surrogacy services are excluded; long-term (>90 days) cryopreservation generally not covered unless member in active treatment.

Surrogate — definition

DefinitionA surrogate is a person who carries and delivers a child for another either through artificial insemination or surgical implantation of an embryo.

Context noteTerm used in infertility exclusions to identify costs and services related to surrogacy that are excluded from coverage.

Source referenceSee Infertility related services and exclusions for specific cost exclusions when a surrogate is used.

Gestational carrier — definition

DefinitionA gestational carrier is a surrogate with no biological connection to the embryo/child.

Coverage implicationCosts for use of a gestational carrier (including drugs, embryo transfer, cryopreservation, maternity care when carrier is not a member) are excluded.

Cross-referenceSee infertility exclusions for details on cryopreservation limits and donor/gestational carrier exclusions.

Document History

Document history — CPT/HCPCS additions and listingsmixed

0442T	0442T
0443T	0443T
G2001	G2001
J0270	J0270
15769	15769
81440	81440

(Document History entries — no single publication date provided)codes_added_or_listedLatest

Multiple CPT/HCPCS/T/G/J/K/L/M/P/Q/S/T/V code additions and listings were recorded in the document history (examples include 0442T–0566T series, G2001–G2125 ranges, 0703T–0709T, 15769, 81440, 81465, and numerous K/L/Q/S/T code ranges).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage Exclusions and Non‑Covered Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm DME and procedure codes are not listed as non-covered before billing and provide required documentation for replacement of stolen or destroyed DME.

SourceLink

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