Neighborhood Health Plan RI DME Exclusions & Coverage

Non‑Covered Services and Exclusions

Not covered / Exclusions

Services and items listed below are not covered (policy not all-inclusive).

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: routine services associated with investigational or experimental cancer treatments are covered per state regulation.

DME exclusions: Purchase, repair, or replacement of materials or equipment resulting from member 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 department, or insurance report if applicable); repair of Neighborhood non-covered DME items; repair of DME items covered under the provider's or manufacturer's warranty; repair of a rented DME item.

Circumcisions not covered if performed outside a hospital, day surgery, or physician's office.

Cosmetic services: Procedures or services intended to change or improve appearance without significantly improving physiological function are not covered. Examples include cervicoplasty; chemical peels and dermabrasion; augmentation mammoplasty, mastopexy and correction of congenital breast asymmetry; cosmetic prosthetic devices; excision of excess skin (except panniculectomy); genioplasty; gynecomastia surgery; hair removal and transplants; inverted nipple surgery; laser treatment for acne/scars; liposuction; osteoplasty; otoplasty; rhinoplasty; rhytidectomy; scar revision; sclerotherapy for spider veins; subcutaneous injection of filling material; tattooing/tattoo removal (except nipple/areola post-mastectomy); testicular prosthesis surgery; treatment of vitiligo; and related incidental charges.

See full cosmetic procedure list in source

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

Home modifications: Permanent home modifications and items for use in the home are not covered, including 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/arms; and telephone service in the home.

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

Additional exclusions: A broad list of additional non-covered items and services including academic testing; concierge fees; dehumidifiers; air purifiers/HEPA filters; drugs/devices for sexual or erectile dysfunction; health club memberships; LASIK; medical marijuana; personal emergency response systems; planned home births; sperm banking; waterproof casts; weighted vests and blankets; wigs (except for alopecia and cancer treatment); vitrectomy chairs; and others.

Infertility — Not covered conditions

Infertility-related services are not covered when any of the following apply:

Infertility exclusions: Members who do not meet the definition of Infertility; experimental infertility procedures; medical or surgical procedures for reversal of voluntary sterilization; costs of surrogacy or gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation of embryos, use of donor egg with a gestational carrier, and maternity care if the surrogate is not a member); long-term (>90 days) sperm or embryo cryopreservation unless the member is in active infertility treatment (short-term <90 days may be authorized in select medical conditions); costs associated with donor recruitment and compensation; donor sperm and associated laboratory services in the absence of diagnosed male factor infertility in the partner; procurement of frozen donor oocytes; and services for couples in which one partner has had a previous sterilization procedure.

Non-covered services — Miscellaneous

Additional non-covered categories and specific exclusions include, but are not limited to:

Alternative therapies: Animal therapy; dance therapy; psychodrama; transcendental meditation; yoga; hypnotherapy; and other alternative/holistic services. (Biofeedback is excluded except for urinary incontinence as noted in policy.)

Cosmetic services: Procedures to change or improve appearance without significant physiologic benefit are not covered — examples provided in the cosmetic services list such as cervicoplasty, chemical peels, augmentation mammoplasty, excision of excess skin (except panniculectomy), hair removal/transplants, rhinoplasty, facelifts, scar revision, tattooing (except nipple/areola post-mastectomy), testicular prosthesis, treatment of vitiligo, and others.

Devices/Appliances/Prosthetics: 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 and cranial banding); some 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.

Network Restrictions

Network and place-of-service rules:

Network restriction: Services must be rendered by network providers unless it is an emergency or prior approval has been received. Any services, programs, supplies or procedures provided in a nonconventional setting (for example, spas/resorts; educational, vocational, or recreational settings; outward bound or wilderness programs; or services performed outside the United States and its territories) are excluded even if provided by licensed providers.

Over-the-counter contraceptives

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

Not covered / Exclusions

Services listed below are excluded from coverage unless otherwise noted by policy or by specific medical necessity exception:

Network and setting rules: Services must be rendered by network providers unless emergency or prior approval; services in nonconventional settings are excluded (e.g., spas, resorts, educational/vocational/recreational settings, wilderness programs, services outside the U.S.).

See policy for examples.

Explicitly excluded service categories: Over-the-counter contraceptive agents; pediatric vision services not meeting accepted standards (including replacement of lost/stolen eyewear and non-prescription lenses); reversal of voluntary sterilization; sexual and/or erectile dysfunction treatments except when medically necessary for treatment related to an organic condition; cryopreservation, storage and thawing of reproductive tissue; procedures to alter body contours for aesthetic reasons (except gynecomastia and gender dysphoria treatment); voice modification surgery; reversal of genital surgery; transportation by chair car/wheelchair van/taxi; and a broad list of additional exclusions including concierge fees, medical marijuana, TENS units and other neuromuscular stimulators and related supplies, vitrectomy chairs, waterproof casts, weighted vests and blankets, and personal emergency response systems.

See detailed exclusion lists in source chunks.

The policy explicitly excludes a broad set of cosmetic procedures and services. Cosmetic procedures are defined as services that change or improve appearance without significantly improving physiological function. Examples of non‑covered cosmetic services include, but are not limited to: cervicoplasty; chemical exfoliations/peels/dermabrasions; augmentation mammoplasty and mastopexy; cosmetic prosthetic devices; 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; osteoplasty; otoplasty; removal/destruction of skin tags; rhinoplasty; rhytidectomy (facelift); scalp hair prostheses and wigs for non‑covered indications; scar revision; sclerotherapy for spider veins; subcutaneous injection of filling material; tattooing/tattoo removal (except areola/nipple related to mastectomy); testicular prosthesis surgery; and treatment of vitiligo.

Permanent home alterations and environmental accessibility modifications are excluded. Non‑covered examples include decks; permanent lifts affixed to the home; enlarged doorways; grab bars and ramps; fences; handrails; room additions or expansions; and home telephone alert/arm/service systems.

Infertility‑related arrangements and certain reproductive tissue services are excluded. Not covered are the costs of surrogacy or gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation, and maternity care when the surrogate is not a member); long‑term sperm or embryo cryopreservation (>90 days) unless the member is in active infertility treatment; donor recruitment and compensation; procurement of frozen donor oocytes; donor sperm and associated laboratory services when there is no diagnosed male factor infertility; and services for members who do not meet the definition of infertility or for experimental infertility procedures. Prior authorization is recommended for drugs for anonymous or designated egg donors directly related to a stimulated ART cycle.

Specific durable medical equipment, devices and appliances are listed as non‑covered. Examples include dehumidifiers; devices used solely as safety items or to affect sports performance; orthotic appliances that straighten or re‑shape anatomy (e.g., foot orthotics, cranial banding); certain 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. Refractive eye surgery (and deluxe frames) are also noted under vision exclusions.

Multiple miscellaneous services and items are explicitly excluded. Key examples: over‑the‑counter contraceptive agents; pediatric vision services or supplies not meeting covered standards (including replacement of lost/stolen eyewear and non‑prescription lenses); reversal of voluntary sterilization; most sexual/erectile dysfunction treatments except when medically necessary for an organic condition; cryopreservation, storage and thawing of reproductive tissue; transportation by chair car/wheelchair van/taxi; concierge service fees; medical marijuana; personal emergency response systems; TENS units and other neuromuscular stimulators and related supplies; vitrectomy chairs; waterproof casts; weight loss programs; weighted vests and blankets; and other listed ancillary or convenience items.

Services performed solely to change or improve appearance without a significant physiological benefit are considered cosmetic and are not covered. The policy follows the definition that cosmetic procedures do not significantly improve physiological function and therefore do not meet medical necessity criteria.

The policy reiterates that treatments described as cosmetic—procedures intended to alter or improve appearance without materially improving physiological function—are not medically necessary and are excluded. The document provides an extensive, itemized list of such procedures to guide coverage determination and claim adjudication.

Treatments for sexual and erectile dysfunction are excluded unless they are medically necessary to treat an identified organic condition. Procedures primarily for sexual enhancement or dysfunction without organic cause are not covered under this policy.

Codes and External Code Grids

External non-covered code gridsmixed

No codes listed

Provider Requirements, Prior Authorization, and Denial Risks

Documentation Required

DME exclusions and required documentation

Purchase, repair, or replacement of DME will be denied when resulting from member abuse. Repairs of DME items that are covered under a provider's or manufacturer's warranty, repairs of rented DME items, and repair of Neighborhood non-covered DME items are not covered. For items alleged to be stolen or destroyed, provide documentation for consideration: an explanation of continuing medical necessity for the item, an explanation that the item was stolen or destroyed, and a copy of the police, fire department, or insurance report if applicable.

Purchase/repair/replacement due to member abuse — denied
Repair of DME under warranty — not covered
Repair of rented DME — not covered
Stolen/destroyed DME — require documentation: explanation of continuing medical necessity; explanation that item was stolen/destroyed; police/fire/insurance report if available

Denial Risk

Key Definitions

inv-31: Cosmetic Procedure — Definition

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

Coverage stanceServices, supplies or medications intended solely to change or improve appearance are not covered except as described in covered services.

Examples notedIncludes, but is not limited to, the extensive list of cosmetic procedures enumerated in the policy (see Cosmetic Services section).

inv-32: Cosmetic Surgery — Definition

Definition (ASPS)Per the American Society of Plastic Surgeons: surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Context

DME Medical Necessity and Replacement Rules

DME replacement after theft/destruction

DME replacements due to theft or destruction may be considered when documentation provided.

Stolen/Destroyed DME documentation: Member or provider must submit: (1) explanation of continuing medical necessity for the item; (2) explanation that the item was stolen or destroyed; and (3) copy of police, fire department, or insurance report if applicable. Replacement consideration is only when this documentation is provided.

DME — Not covered items

DME items listed as non-covered are not reimbursed; items explicitly excluded are considered not medically necessary.

Excluded DME: 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 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, snore guards); electric hospital-grade breast pump purchases; personal emergency response systems; TENS units and related supplies; vitrectomy chairs; waterproof casts; weighted vests and blankets; and other DME items listed in Additional Coverage Exclusions.

DME Rental, Warranty, and Purchase Conditions

DME category	Policy summary
Rented DME
Repair of a rented DME item is not covered.

DME category	Policy summary
Warrantied DME
Repair of DME items covered under the provider's or manufacturer's warranty is not covered.

Documentation Requirements

Documentation Required

Submit theft/destruction evidence and medical necessity for replacement

Submit documented evidence of theft or destruction plus documentation of continuing medical necessity when requesting replacement consideration for stolen or destroyed DME.

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

Billing Rule

Do not bill excluded items as DME without supporting documentation

Do not bill explicitly non-covered items as DME; if requesting coverage as an exception, include documentation supporting medical necessity and follow authorization procedures.

Do not submit claims for listed excluded devices expecting DME coverage

Explicitly Not Covered Items

DME repairs, purchases, or replacements resulting from member abuse are not covered. Replacement or repair for items that were stolen or destroyed is not covered unless the provider submits documentation including an explanation of continuing medical necessity; explanation that the item was stolen or destroyed; and a police, fire department, or insurance report if applicable. Also excluded are repair of non‑covered DME items, repair of items covered under provider or manufacturer warranty, and repair of rented DME items.

Dehumidifiers are specifically listed as not covered. In addition, electric hospital‑grade breast pump purchases are excluded from coverage; such device and appliance exclusions may result in claim denial if billed as DME.

Dehumidifiers are listed among non‑covered DME items. The policy also excludes electric hospital‑grade breast pump purchases from reimbursement.

The policy names dehumidifiers as a non‑covered item and excludes purchases of electric hospital‑grade breast pumps from coverage. Providers should not bill these items as reimbursable DME.

Dehumidifiers are explicitly non‑covered. Electric hospital‑grade breast pump purchases are also not covered by the plan and should not be submitted for reimbursement.

Dehumidifiers are included on the non‑covered devices list. Electric hospital‑grade breast pump purchases are similarly excluded from coverage and reimbursement.

Dehumidifiers and purchases of electric hospital‑grade breast pumps are designated non‑covered items. Claims for these items may be denied.

OpenPayer

Non‑covered Services and Durable Medical Equipment (DME) Exclusions