Neighborhood Health Plan RI DME Exclusions & Coverage

Not Covered Services and Exclusions

inv-01: Not Covered Services

Services and items are not covered when listed in the following categories.

Investigational/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.

DME Exclusions: Purchase, repair, or replacement of materials or equipment when the result of enrollee abuse; purchase/repair/replacement of items that have been stolen or destroyed except when documentation is provided; 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.

Documentation required for stolen/destroyed items: explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and copy of police/fire/insurance report if applicable.

Non-DME Items: Household and consumer items such as air conditioners (window or central), air cleansers/purifiers/HEPA filters, dehumidifiers, floor mats, trampolines (including mini), suspension swings, hypoallergenic pillows/bedding, standard car seats, food products for specialty diets, waterproof casts, and similar non-medical equipment are not covered.

List not exhaustive.

Cosmetic Services: Procedures or services to change or improve appearance without significantly improving physiological function (cosmetic procedures/surgery) are not covered. Examples include cervicoplasty; chemical peels/exfoliation/dermabrasion; augmentation mammoplasty, mastopexy; excision of excess skin (except panniculectomy); genioplasty; gynecomastia surgery; hair removal/transplants; inverted nipple surgery; laser treatment for acne/scars; liposuction; facial bone reduction; scar revision; rhinoplasty; rhytidectomy (facelift); tattooing or tattoo removal (except nipple/areola tattoo related to mastectomy); and other listed cosmetic procedures.

Medically necessary procedures performed at the same time as a cosmetic procedure are also addressed in the cosmetic services list.

Dental: Orthodontia and all dental services are not covered except for emergency dental and limited oral surgery.

Infertility-related items and services are generally not covered: home ovulation prediction kits; infertility treatment for members who do not meet the definition of infertility; experimental infertility procedures; costs of surrogacy or gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation, donor egg use, maternity care when surrogate 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 conditions); donor recruitment and compensation; services related to conception after voluntary sterilization or unsuccessful reversal; donor sperm and associated lab services absent diagnosed male factor infertility; procurement of frozen donor oocytes; and related exclusions.

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

Alternative Therapies: Alternative and complementary therapies are not covered, including animal therapy, dance therapy, massage therapy, psychodrama, yoga, transcendental meditation, hypnotherapy and other listed alternative/holistic services (biofeedback excluded except for urinary incontinence treatment).

Additional General Exclusions: Additional exclusions include but are not limited to academic testing, chronic care management services, diagnostic tests to evaluate the need for a noncovered service, drugs/devices for sexual or erectile dysfunction, health club memberships, LASIK surgery, medical marijuana, planned home births, private hospital rooms (unless medically necessary), sperm banking, wigs except for alopecia/cancer, lodging, transportation (chair car/wheelchair van/taxi), and other items/services listed in the exclusions sections.

inv-02: Not Covered / Exclusions

The following services, supplies, procedures, and settings are not covered:

Infertility and related services exclusions: 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 of embryos, use of donor egg, maternity care if surrogate 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 conditions); donor recruitment/compensation and procurement of frozen donor oocytes; donor sperm and lab services absent diagnosed male factor infertility; services for conception after voluntary sterilization or unsuccessful reversal.

Prior authorization is recommended for drugs for anonymous or designated egg donors related to a stimulated ART cycle when member is not the sole recipient of donor's eggs.

Cosmetic services exclusions: Procedures or services to change or improve appearance without significantly improving physiological function are not covered. Listed examples include cervicoplasty, chemical peels/exfoliations/dermabrasion, augmentation mammoplasty, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplants, inverted nipple surgery, laser treatments for acne/scarring, liposuction, osteoplasty, otoplasty, rhinoplasty, facelifts, scar revision, tattooing/tattoo removal (except nipple/areola related to mastectomy), and other specified cosmetic procedures.

inv-03: Exclusions / Not Covered

Explicit exclusions and not-covered items

Lodging and related exclusions: Lodging is not covered even when related to receiving any medical service; private rooms in hospitals are not covered unless medically necessary.

Over-the-counter and pediatric vision exclusions: Over-the-counter contraceptive agents are not covered. Pediatric vision care excludes services and materials not meeting accepted standards of optometric practice, special lens designs/coatings beyond covered services, replacement of lost/stolen eyewear, non-prescription lenses, and insurance of contact lenses.

Sterilization and sexual dysfunction exclusions: Medical or surgical procedures for reversal of voluntary sterilization are excluded. Services and treatments for sexual and/or erectile dysfunction are excluded except when medically necessary for treatment related to an organic condition.

Gender dysphoria and related exclusions: Exclusions include cryopreservation, storage and thawing of reproductive tissue, procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons (considered cosmetic) except for gynecomastia and gender dysphoria treatment, voice modification surgery, and reversal of genital surgery.

The policy enumerates specific DME-related exclusions. Purchase, repair, or replacement of DME resulting from enrollee abuse is not covered. Replacement of DME that has been stolen or destroyed is not covered unless documentation is submitted demonstrating ongoing medical necessity, an explanation that the item was stolen or destroyed, and a police/fire/insurance report if applicable. Also excluded are repair of DME items not covered by Neighborhood, repair of DME items covered under a provider’s or manufacturer’s warranty, and repair of a rented DME item. In addition, several household items that are non-medical in nature (for example, dehumidifiers, certain window/central air conditioners, air purifiers/HEPA filters, floor mats, trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, specialty diet food products, and waterproof casts) are listed as non-covered non-DME items.

The exclusions include a range of clinical and non‑clinical services. Abortion services are excluded except when necessary to preserve the life of the woman or in cases of rape or incest. Cosmetic procedures and surgeries that are intended to change or improve appearance without significantly improving physiological function are not covered (see cosmetic lists). Device and prosthetic exclusions include items such as dehumidifiers, orthotic appliances that reshape a body part (e.g., foot orthotics, cranial banding), certain over‑the‑counter braces, devices to reduce snoring, and electric hospital‑grade breast pump purchases. Human organ transplant exclusions include experimental transplant procedures (unless required by law), donor services not directly related to transplant, donor search expenses, and cord blood collection/preservation costs. Infertility‑related exclusions are discussed separately (including surrogacy and long‑term cryopreservation rules).

Services rendered in nonconventional settings are excluded. Lodging is explicitly not covered even when related to receiving medical services. The policy also states that services must be performed by network providers unless it is an emergency or prior approval has been obtained; any services, programs, supplies, or procedures provided in settings such as spas/resorts, educational/vocational/recreational settings, outward bound/wilderness/camp/ranch programs, or services performed outside the United States and its territories are excluded even if delivered by licensed professionals.

The document contains extensive enumerated code lists identifying specific ICD‑10, ICD‑10‑PCS, CPT, and HCPCS codes that are excluded from coverage under the headings for Medicaid, INTEGRITY, and Commercial lines. Providers should consult the Non‑Covered Services sections for the full code lists when submitting claims, as services billed with those codes will be treated as non‑covered.

Separate code lists are provided for the INTEGRITY and Commercial non‑covered services sections. These sections include both diagnosis (ICD‑10) and procedure (ICD‑10‑PCS, CPT, HCPCS) code ranges and numerous individual HCPCS and CPT codes identified as non‑covered. Claims containing codes from these lists are subject to denial as non‑covered under the respective line of business.

Cosmetic procedures are defined as services or procedures intended to change or improve appearance without significantly improving physiological function. The policy follows the standard distinction that cosmetic surgery reshapes normal body structures to improve appearance and self‑esteem. Accordingly, procedures performed solely for appearance enhancement are considered not medically necessary and are excluded unless specifically described as a covered service.

The policy lists numerous cosmetic procedures and services that are considered not medically necessary and therefore not covered. Examples include, but are not limited to: augmentation mammoplasty, mastopexy, cervicoplasty, chemical peels/dermabrasion, excision of excess skin (except panniculectomy), liposuction, rhinoplasty, rhytidectomy (facelift), scar revision, hair removal/transplants, tattooing or tattoo removal (except nipple/areola tattoo related to mastectomy), and testicular prosthesis surgery. Medically necessary procedures performed at the same time as a cosmetic procedure are also addressed in the policy and the cosmetic exclusion generally applies unless an exception is specified.

Services, supplies, or medications that are required by a third party but are not otherwise medically necessary are excluded. Examples include items or services required by an employer, school, insurer, or court when such items do not meet medical necessity criteria for the member.

Non-Covered Codes and Code Ranges

Non-covered CPT codes (Medicaid / INTEGRITY / Commercial samples)CPTNot Covered

0010M	Non-covered (see policy)
0012M	Non-covered (see policy)
0013M	Non-covered (see policy)
0141T	Non-covered (see policy)
0142T	Non-covered (see policy)
0143T	Non-covered (see policy)
0203T-0222T	Non-covered range
0223T-0225T	Non-covered range
0232T	Non-covered
0233T	Non-covered

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Requirements for Providers — Authorization, Network & Billing

Prior Authorization

Network restriction / prior approval

Services must be rendered by in-network providers unless it is an emergency or prior approval has been obtained. Prior approval is required for out-of-network services to avoid denial; when emergency care is claimed from a non-network provider, submit supporting emergency documentation. Any services, programs, supplies, or procedures provided in nonconventional settings are excluded (examples: spas/resorts, educational/vocational/recreational settings, wilderness/camp programs, services performed outside the United States and its territories). This exclusion applies even if performed by licensed providers. Providers should follow payer-specific authorization rules for Medicaid (excluding EFP), INTEGRITY, and Commercial.

Prior approval required for out-of-network services to avoid denial; emergency documentation may be required
Nonconventional setting services are excluded even if performed by licensed providers
Follow payer-specific authorization rules (Medicaid excluding EFP, INTEGRITY, Commercial)

DME Medical Necessity and Replacement Rules

inv-54: DME Replacement Criteria

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

Stolen/Destroyed DME Replacement: Member must provide 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.

Submit documentation with claim/authorization to support replacement consideration.

inv-55: DME Not Covered

Items listed are generally not covered unless a specific exception applies.

DME exclusions: Dehumidifiers; devices used specifically as safety items or to affect sports 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.

Rules for Rented and Purchased Durable Medical Equipment

Item / Situation	Policy Rule	Coverage
Repair of a rented DME item	Repair of DME items that are rented to the member is explicitly excluded from coverage.	Repair of rented DME items
Purchase, repair, or replacement due to enrollee abuse	Purchase, repair, or replacement of materials or equipment when the need is the result of enrollee abuse is excluded.	Abuse-related DME services
Purchase, repair, or replacement of stolen or destroyed items	Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed is not covered unless documentation is provided (explanation of continuing medical necessity; explanation that item was stolen or destroyed; copy of police, fire department, or insurance report if applicable).	Stolen or destroyed DME (with required documentation may be considered)
Repair of DME items covered under provider's or manufacturer's warranty	Repair of DME items that are covered under the provider's or manufacturer's warranty is excluded from coverage.	Warranty-covered DME repairs
Repair of DME items not covered by Neighborhood	Repair of DME items that are not covered by Neighborhood is excluded.	Repairs for DME not covered by Neighborhood

Documentation Requirements

Documentation Required

Submit documentation for stolen/destroyed DME with claim/authorization

When replacing a stolen or destroyed DME item, submit with the claim or authorization the explanation of continuing medical necessity, explanation that the item was stolen or destroyed, and a police/fire/insurance report if applicable.

Explanation of continuing medical necessity
Explanation that item was stolen or destroyed
Police, fire department, or insurance report, if available

Documentation Required

Provide prior approval or emergency justification for out‑of‑network care

For services rendered by out‑of‑network providers, include prior approval documentation or documentation that supports an emergency to avoid claim denial.

Documentation Required

Specific Not Covered Items (detailed lists)

The policy specifies that purchase, repair, or replacement of DME due to enrollee abuse is not covered. Repair of rented DME items is not covered. Repairs that are the responsibility of the provider’s or manufacturer’s warranty are excluded from coverage. Replacement of stolen or destroyed DME may be considered only when supporting documentation is provided (explanation of continuing medical necessity, explanation of theft/destruction, and police/fire/insurance report if applicable).

Certain household and orthotic items are explicitly listed as non‑covered. Dehumidifiers are identified as non‑covered non‑DME household equipment. The policy also excludes orthotic appliances that straighten or reshape a body part (for example, foot orthotics and cranial banding) and notes some types of braces — including over‑the‑counter orthotic braces — are excluded. These items are listed among other device and household exclusions.

The policy reiterates that household devices such as dehumidifiers are not covered. It also restates that orthotic appliances intended to straighten or reshape body parts (notably foot orthotics and cranial banding) are excluded, consistent with the devices and prosthetics exclusions.

Dehumidifiers and orthotic appliances that reshape body parts (e.g., foot orthotics, cranial banding) appear repeatedly in the non‑covered lists; the policy consistently treats these as excluded items.

The exclusions include repeated listings of household and orthotic items—such as dehumidifiers and foot orthotics/cranial banding—that are treated as non‑covered across the policy sections.

Across multiple sections the policy lists dehumidifiers and orthotic appliances that straighten or reshape body parts (for example, foot orthotics and cranial banding) as not covered items.

Key Definitions

Cosmetic Procedure / Cosmetic Surgery definition

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

Cosmetic surgery (ASPS)Surgery performed to reshape normal structures of the body to improve appearance and self‑esteem (per American Society of Plastic Surgeons).

Examples (non‑exhaustive)Cervicoplasty, chemical peels, augmentation mammoplasty, excision of excess skin (except panniculectomy), genioplasty, gynecomastia surgery, hair removal/transplants, liposuction, osteoplasty.

Surrogate / Gestational carrier

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

Gestational carrier

OpenPayer

Non‑Covered Services and DME Exclusions — Coverage Criteria

Not Covered Services and Exclusions

Non-Covered Codes and Code Ranges

Requirements for Providers — Authorization, Network & Billing

DME Medical Necessity and Replacement Rules

Rules for Rented and Purchased Durable Medical Equipment

Documentation Requirements

Specific Not Covered Items (detailed lists)

Key Definitions