Neighborhood Health Plan RI non-covered DME Coverage

Coverage Exclusions and Criteria

Investigational / Experimental

Investigational or experimental services are considered non-covered except where state regulation provides otherwise.

Investigational/Experimental Exclusions: Service is investigational or experimental as defined by lacking FDA approval, being the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials, or services delivered in connection with or required by an item or service that is not covered.

Exception: investigational or experimental services are covered for cancer treatment per State regulation.

DME Exclusions

DME-related exclusions.

DME Exclusions: Purchase, repair, or replacement of DME that is the result of enrollee abuse is excluded.

Stolen/Destroyed DME: Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed is excluded except when the member provides: explanation of continuing medical necessity; explanation that the item was stolen or destroyed; and copy of police, fire department, or insurance report if applicable.

Documentation listed is required to consider replacement.

Warranty or Rental Repairs: Repair of DME items that are not covered by Neighborhood, repair of items covered under provider's or manufacturer's warranty, and repair of rented DME items are excluded.

Non-DME Exclusions

Non-DME items explicitly excluded.

Household & Consumer Items: Items such as air conditioners (window or central), air cleansers/purifiers/HEPA filters, dehumidifiers, floor mats, trampolines/mini trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, food products for specialty diets, and waterproof casts are not covered.

Lists are illustrative and not all-inclusive.

Cosmetic Exclusions

Cosmetic services excluded.

Cosmetic Exclusions: Procedures, services, supplies or medications intended to change or improve appearance without significantly improving physiological function are not covered. Examples include (but are not limited to) cervicoplasty, chemical peels/dermabrasion, augmentation mammoplasty, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplant, inverted nipple surgery, laser treatment for acne/scars, liposuction, otoplasty, rhinoplasty, rhytidectomy, scar revision, tattooing/tattoo removal (except nipple/areola related to mastectomy), testicular prosthesis, treatment of vitiligo, subcutaneous injection of filling material, and related drugs and professional fees.

Medically necessary procedures performed at the same time as a cosmetic procedure may be addressed separately in covered services.

Dental

Dental exclusions.

Dental Exclusions: Orthodontia and all dental services are excluded except for emergency dental services and limited oral surgery, which are exceptions to this exclusion.

Emergency dental and limited oral surgery remain covered per policy exceptions.

Home Modifications

Home modification exclusions.

Home Modifications: Permanent home modifications and structural changes are excluded, including decks, permanent lifts (affixed to the home), enlarged doorways, environmental accessibility modifications (grab bars, ramps), fences, handrails, room additions/expansions, and telephone alert systems/telephone arms/telephone service in the home.

Permanent lifts affixed to the home are excluded; bed-to-chair lifts are not detailed here.

Infertility

Infertility-related exclusions.

Infertility Exclusions: Home ovulation prediction kits and a broad set of infertility-related services are excluded. Infertility treatment is not covered for members who do not meet the definition of infertility, for experimental infertility procedures, or for services related to surrogacy and gestational carriers (including drugs for implantation, embryo transfer, and cryopreservation). Long-term (>90 days) sperm or embryo cryopreservation is excluded unless the member is in active infertility treatment (short-term <90 days may be authorized for certain medical conditions). Costs associated with donor recruitment/compensation, procurement of frozen donor oocytes, donor sperm and lab services when no diagnosed male factor infertility, and services for couples with prior sterilization are excluded. Drugs for anonymous or designated egg donors related to stimulated ART cycles are excluded unless the member is the sole recipient; prior authorization is recommended for these services.

See policy for detailed exceptions and prior authorization guidance for donor egg drugs.

Alternative / General Exclusions

Alternative therapies and additional general exclusions.

Alternative Therapies: Alternative therapies are excluded, including animal therapy, dance therapy, massage therapy, psychodrama, transcendental meditation, yoga, alternative/holistic/naturopathic services, hypnotherapy, and biofeedback except for urinary incontinence.

General Exclusions: Other general exclusions include academic performance testing, altered auditory feedback devices, chronic care management services, diagnostic tests to evaluate need for a non-covered service, drugs/devices for sexual or erectile dysfunction, educational testing/training programs, health club memberships, LASIK, 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, and wigs except for alopecia and cancer treatment.

List is illustrative, not all-inclusive.

Infertility — Not Covered

Not covered when any of the following conditions apply:

Infertility — Not Covered: Services are not covered for members who do not meet the definition of infertility; experimental infertility procedures; medical or surgical reversal of voluntary sterilization; costs of surrogacy including drugs for implantation, embryo transfer, and cryopreservation of embryos; use of donor egg with a gestational carrier; maternity care for a surrogate who is not a member; 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/compensation; infertility services necessary after voluntary sterilization or unsuccessful reversal; donor sperm and associated lab services in the absence of diagnosed male factor infertility; procurement of frozen donor oocytes; and drugs for anonymous/designated egg donors related to stimulated ART cycles unless the member is the sole recipient.

Prior authorization is recommended for drugs for anonymous or designated egg donors related to stimulated ART cycles.

General Exclusions

The payer does not cover the following categories or services:

Alternative therapies: Animal therapy; Dance Therapy; Psychodrama; Transcendental Meditation; Yoga; alternative/holistic/naturopathic services; hypnotherapy; and biofeedback (except for urinary incontinence) are excluded.

Cosmetic services: Procedures, supplies and services to change or improve appearance without significant physiologic benefit are excluded (see cosmetic exclusions for examples such as cervicoplasty, chemical peels, augmentation mammoplasty, excision of excess skin except panniculectomy, genioplasty, gynecomastia surgery, hair removal/transplant, laser treatments, liposuction, otoplasty, rhinoplasty, rhytidectomy, scar revision, tattooing/tattoo removal, and related professional fees and supplies).

Devices & Appliances: Devices and appliances such as dehumidifiers, devices used for safety or sports performance, orthotic appliances that reshape body parts (foot orthotics, cranial banding), some braces including over-the-counter orthotic braces, devices/procedures to reduce snoring, and electric hospital-grade breast pump purchases are excluded.

Network and Setting Exclusions

Coverage limits related to provider network and setting:

Network requirement: Services must be rendered by network providers unless it is an emergency or prior approval has been received.

Nonconventional settings excluded: Any services, programs, supplies or procedures provided in nonconventional settings (spas/resorts; educational, vocational, or recreational settings; outward bound/wilderness camp or ranch programs; services performed outside the United States and territories) are excluded even if provided by licensed providers.

Examples include psychotherapy, ABA services, and nutritional counseling when provided in excluded settings.

The following non-DME household items and consumer products are excluded from coverage: air conditioners (window or central), air cleansers/purifiers/HEPA filters, dehumidifiers, floor mats, trampolines and mini-trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, specialty food products for diets, and waterproof casts. These items are identified as non-DME and are not payable under the plan.

Cosmetic procedures and services that are intended solely to change or improve appearance without providing significant physiologic benefit are excluded. Examples include cervicoplasty, chemical peels/dermabrasion, augmentation mammoplasty, mastopexy, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplantation, inverted nipple surgery, laser treatments for acne/scarring, liposuction, otoplasty, rhinoplasty, rhytidectomy, scar revision, tattooing or tattoo removal (except nipple/areola related to mastectomy), testicular prosthesis, and related drugs, devices, and professional fees.

An extensive set of services, devices, and support costs are explicitly excluded. This includes broad cosmetic exclusions (procedures or supplies to change appearance), specific device and appliance exclusions (e.g., dehumidifiers; orthotic appliances intended to re-shape body parts; certain braces; devices to reduce snoring; electric hospital-grade breast pump purchases), infertility- and surrogacy-related costs (donor procurement/compensation, donor egg/gestational carrier use, long-term cryopreservation beyond allowed short-term exceptions), lodging, and custodial/supportive services. These categories are illustrative of many listed exclusions and are not all-inclusive.

Lodging expenses are not a covered benefit under the plan. Lodging is excluded even when related to receiving medical services (for example, travel- or lodging-related costs associated with treatment or procedures).

Services must generally be provided by network providers to be covered. Non-network services will be denied unless the care is an emergency or prior approval has been obtained. Additionally, services, programs, supplies or procedures delivered in nonconventional settings (for example, spas/resorts, educational/vocational/recreational settings, outward-bound or wilderness programs, or services performed outside the United States and territories) are excluded even if provided by licensed professionals.

Over-the-counter contraceptive agents are excluded from coverage. These agents are not payable when billed or supplied to members under the plan.

Pediatric vision care exclusions include services and materials that do not meet accepted optometric standards, special lens designs or coatings beyond described covered services, replacement of lost or stolen eyewear, non-prescription (plano) lenses, providing two pairs in lieu of bifocals, and insurance of contact lenses. These items are not covered for pediatric vision care.

Reversal of voluntary sterilization (medical or surgical procedures to reverse sterilization) is excluded from coverage. Such procedures are specifically listed as not covered.

Services and treatments for sexual and/or erectile dysfunction are excluded except when medically necessary for treatment of an identified organic condition. Claims for sexual dysfunction therapies will be denied unless documentation supports a medically necessary indication related to an organic disorder.

Treatments and procedures associated with sexual reassignment or gender dysphoria are excluded as described. Exclusions specifically call out cryopreservation/storage/thawing of reproductive tissue, voice modification surgery, reversal of genital surgery, and cosmetic procedures to alter masculinity/femininity or body contours (exceptions noted only where treatment of gynecomastia or specific gender dysphoria rules apply).

Transportation services such as chair car, wheelchair van, taxi, or similar nonemergency transport are excluded and are not reimbursable under the plan.

Additional general exclusions include provider charges for missed appointments, fees for copying or forwarding member records/charts/X-rays, chronic care management services, electrolysis, educational or developmental evaluations, exercise classes, medical marijuana, personal emergency response systems, personal trainer fees, relaxation/massage therapies, TENS units and related supplies, waterproof casts, weight loss programs, and other listed miscellaneous items. These items are not covered benefits.

The policy includes extensive, plan-specific non-covered code lists. CPT, HCPCS, ICD-10 Procedure, and diagnosis codes enumerated in the Non-Covered Services sections for Medicaid, INTEGRITY, and Commercial populations are explicitly non-covered and claims billed with these codes are at risk of denial. Providers must reference the specified non-covered code pages for each line of business before submitting claims.

For commercial members the document contains extensive lists of non-covered CPT, HCPCS and ICD-10-PCS codes (see the Commercial non-covered sections). These codes are explicitly identified as non-covered for commercial lines and prior authorization will not render them payable when listed.

Services, supplies, or medications offered solely to change or improve appearance without a significant physiologic benefit are not medically necessary and therefore not covered. Cosmetic procedures are defined as interventions that improve appearance without materially improving physiological function and are designated not medically necessary in the policy.

Cosmetic procedures are defined in this policy as procedures that change or improve appearance without significantly improving physiologic function. Examples listed include facial and body aesthetic surgeries and procedures; such services are excluded unless a specific covered-service exception is documented.

The Medicaid section contains extensive non-covered code listings across CPT and HCPCS and ICD-10 Procedure ranges. These code lists (detailed in the Non-Covered Services: Medicaid sections) identify many procedure and equipment codes that are not payable and should not be submitted for coverage unless plan guidance indicates otherwise.

Non-Covered Codes and Code Lists

Prior Authorization, Billing and Provider Guidance

Note

Applicability to Lines of Business

This policy applies to: Medicaid (excluding Extended Family Planning/EFP), INTEGRITY, and Commercial lines of business. Providers must follow line-of-business specific non-covered lists and authorization rules when submitting claims.

Applies to: Medicaid (excluding EFP); INTEGRITY; Commercial

Denial Risk

Medicaid Non‑Covered — Prior Authorization Not Applicable

For Medicaid members, listed CPT/HCPCS/ICD-10-PCS codes in the Medicaid non-covered lists are designated non-covered. Prior authorization will not make these services covered. Claims billed with these codes are at risk of denial.

Medicaid non-covered code lists are definitive — prior authorization cannot override non-coverage.
Claims with listed Medicaid codes (see policy non-covered lists) may be denied.

Medical Necessity and DME Replacement Rules

DME replacement for stolen/destroyed items

Conditions under which DME replacement may be considered.

Stolen/Destroyed DME Consideration: Replacement may be considered only if the member provides required documentation: explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and a copy of the police, fire department, or insurance report if applicable.

Otherwise purchase/repair/replacement of stolen/destroyed items is excluded.

DME — Not Covered Items

The following DME items and related equipment are not covered.

Excluded DME items: Specific DME and related items are listed as non-covered including 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 braces including over-the-counter orthotic braces; devices and procedures intended to reduce snoring (e.g., laser-assisted uvulopalatoplasty, somnoplasty, snore guards); electric hospital-grade breast pump purchases; TENS units and related neuromuscular stimulation supplies; Personal Emergency Response Systems; and various HCPCS/CPT-listed DME codes shown in the non-covered code lists.

DME Rental and Purchase Guidance

Item	Rule / Note
Rented DME
Repair of a rented DME item is excluded; purchase, repair, or replacement of materials or equipment when the result of enrollee abuse is excluded. Replacement of stolen or destroyed items is excluded unless documentation is provided (explanation of continuing medical necessity; explanation that the item was stolen or destroyed; copy of police, fire department, or insurance report if applicable).

Plan-specific Guidance	Action for Providers
Consult the plan-specific non-covered CPT, ICD-10 Diagnosis, and HCPCS code listings (Medicaid, INTEGRITY, Commercial) contained in the document.
Use the plan-specific non-covered code lists to determine whether an item is treated as non-covered, and to confirm whether rental versus purchase billing rules apply; these lists are not all-inclusive—follow payer guidance on coverage status.

Reserved	Notes
(Reserved)
(Reserved)

Reserved	Notes
(Reserved)
(Reserved)

Documentation Requirements and Evidence

Documentation Required

Documentation required for replacement of stolen/destroyed items

When replacing a stolen or destroyed item, provide an explanation of 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.

Billing Rule

Do not submit for non‑covered devices unless payer authorizes

Do not submit claims for coverage if the device is listed on the plan’s non‑covered device lists (e.g., dehumidifiers, certain orthotics, some braces, electric hospital grade breast pumps) unless prior authorization or payer guidance indicates otherwise.

Explicitly Not Covered Items

Repair services for DME are not covered when the item is specifically excluded by Neighborhood, when repair is covered under the provider's or manufacturer's warranty, or when the item is a rented DME. The policy also excludes purchase, repair, or replacement of DME resulting from enrollee abuse. For stolen or destroyed DME, replacement may be considered only when the required documentation is provided (explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and a police/fire/insurance report when applicable).

Certain home and consumer items (for example, air conditioners, dehumidifiers, trampolines, suspension swings, and waterproof casts) are explicitly identified as non-DME and are not covered. The policy also lists other devices and appliances that are non-covered (see Devices, Appliances and Prosthetics exclusions) and advises providers not to submit items listed as non-covered unless prior authorization or payer guidance indicates otherwise.

A range of DME and related items are listed as not covered in the Medicaid non-covered code lists, including examples such as TENS units and other neuromuscular stimulators, Personal Emergency Response Systems, and many HCPCS equipment codes (see the Medicaid Non-Covered Services sections for full HCPCS/CPT listings). Items billed with codes on these lists should not be expected to be payable.

This policy enumerates clinical services and therapies considered experimental, cosmetic, custodial, or otherwise excluded from coverage. It provides examples across multiple categories (DME, cosmetic surgery, infertility, home modifications, alternative therapies, lodging, transportation, and more) and clarifies that the lists are illustrative and that specific non-covered CPT/HCPCS/ICD-10 code listings are provided in dedicated sections.

The document contains multiple repetitive entries emphasizing that dehumidifiers and similar home-environment appliances are non-covered. These entries are listed across the non-DME and Devices sections and reaffirm that such consumer appliances are excluded.

Definitions and Term Clarifications

Cosmetic Procedure / Cosmetic Surgery

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

Cosmetic surgery noteCosmetic surgery is defined (per the American Society of Plastic Surgeons) as procedures performed to reshape normal structures of the body to improve appearance and self-esteem.

Coverage implicationAny service, supply, or medication provided to change or improve appearance is not covered except as described in covered services.

Surrogate

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

Context

Policy Background and Scope

This policy lists clinical services and therapies considered investigational, experimental, cosmetic, custodial, or otherwise excluded. It includes definitions and examples to guide clinical and billing decisions and directs providers to line-of-business non-covered code lists for specific billing guidance.

Policy Revision History

01/12/22policy_updatedLatest

Policy updated — additional CPT/HCPCS codes added to non-covered lists.

10/15/21policy_updated

Policy updated — additional CPT/HCPC codes added to non-covered lists.

07/15/21policy_updated