Neighborhood Health Plan RI non-covered services Coverage

Non-Covered Services and Exclusions

Non-Covered Services

Services and items listed are not covered unless an explicit exception is stated (for example, investigational cancer treatment per state regulation).

Non-covered categories: Includes investigational/experimental services (drugs or devices lacking FDA approval; services that are the subject of Phase I or II clinical trials or the investigational arm of Phase III); non-DME household items (e.g., air conditioners, air purifiers, dehumidifiers, floor mats, trampolines, suspension swings, waterproof casts); cosmetic procedures and cosmetic surgery (extensive list of procedures that change or improve appearance without significantly improving physiological function); routine dental services for adults and most restorative dental procedures (except emergency/limited oral surgery); infertility-related services and associated costs (including experimental infertility procedures, many donor/surrogacy costs, and long-term cryopreservation limits); alternative and complementary therapies (examples listed in Additional Coverage Exclusions); and a variety of other general exclusions (e.g., LASIK, medical marijuana, personal emergency response systems, wigs except for alopecia or cancer treatment).

See cited chunks for full enumerated lists and exceptions.

Not covered / Exclusions

Explicit exclusions — services and situations that are not covered.

Cosmetic exclusions: Procedures and surgeries that change or improve appearance without significantly improving physiological function are not covered; specific examples include cervicoplasty, augmentation mammoplasty, mastopexy, liposuction/suction-assisted lipectomy, rhinoplasty, rhytidectomy (facelift), scar revision, otoplasty, genioplasty, inverted nipple surgery, hair transplants or hair removal, tattooing/tattoo removal (except nipple/areola tattooing post-mastectomy), sclerotherapy, subcutaneous filler injections, scalp hair prostheses/wigs (except for alopecia/cancer), and other listed cosmetic procedures.

See chunks 22, 23, 13, 14 for detailed enumerations.

Devices, appliances, prosthetics exclusions: Non-covered DME and related devices include dehumidifiers; orthotic appliances that merely straighten or re-shape (e.g., foot orthotics, cranial banding); devices used solely as safety items or to affect sports performance; some braces including over-the-counter orthotic braces; electric hospital grade items listed as non-covered; and devices/procedures intended to reduce snoring (e.g., laser-assisted uvulopalatoplasty, somnoplasty, snore guards).

See chunk 26.

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

See chunk 24.

Dental and vision limited coverage: Routine adult preventive and restorative dental services (example: exams, X-rays, cleanings, restorative care such as implants) are not covered; certain vision/eyewear items and special lens designs/coatings and replacement for lost/stolen eyewear are excluded per the enumerated lists.

See chunk 25 and related coding/list references.

Infertility and reproductive services exclusions: Experimental infertility procedures, services for members who do not meet the definition of infertility, costs related to surrogacy (including maternity care when the surrogate is not a member), donor recruitment/compensation and donor sperm or oocyte procurement except in limited circumstances, long-term (>90 days) sperm or embryo cryopreservation unless the member is in active infertility treatment (short-term <90 days may be authorized for some medical conditions), and costs associated with reversal of voluntary sterilization are not covered.>90 days for long-term cryopreservation

See chunk 16 for details.

Experimental or investigational services: Experimental or investigational organ transplant procedures and other investigational treatments are excluded unless required by federal or state law.

See chunk 29 and chunk 2 for investigational exception for cancer per state regulation.

Gender-affirming / sexual reassignment exclusions: Excluded items include cryopreservation/storage/thawing of reproductive tissue, voice modification surgery, procedures to alter body contours or enhance masculinity/femininity that are cosmetic in nature (exceptions noted for gynecomastia and treatment of gender dysphoria), and reversal of genital surgery.

See chunk 36.

Lodging and transportation: Lodging and most transportation (including transportation by wheelchair van, taxi, or car) are not covered, even when related to receiving medical services.

See chunks 31 and 37.

Non-DME household items are excluded from coverage. Examples include air conditioners (window or central), air cleansers/purifiers or HEPA filters, dehumidifiers, and general household goods such as floor mats. Recreational/home items like trampolines and mini trampolines, and play equipment such as suspension swings are not covered. The policy also lists certain protective items such as waterproof casts as excluded non-DME items.

Cosmetic procedures are not covered when their primary purpose is to change or improve appearance without significantly improving physiological function. The policy (reflecting the American Society of Plastic Surgeons definition) enumerates numerous examples of excluded services, including but not limited to cervicoplasty, augmentation mammoplasty / mastopexy, liposuction / suction-assisted lipectomy, rhinoplasty, rhytidectomy (facelift), scar revision, otoplasty, inverted nipple surgery, hair transplants or hair removal (electrolysis), laser treatments for acne/scars, and cosmetic prosthetic devices. Per policy, cosmetic services and any associated incidental charges are excluded unless specifically described as covered.

The policy expands the exclusions to numerous surgical, procedural, and service categories. Examples include routine adult dental preventive and restorative services (e.g., exams, X-rays, cleanings, fillings, extractions, implants), custodial care and non‑skilled care (including rest care, day care, homemaker services), and experimental or investigational organ transplant procedures except where required by federal or state law. Device and appliance exclusions include orthotic appliances that merely straighten or reshape (e.g., foot orthotics, cranial banding) and certain braces (including some over‑the‑counter orthotic braces). The policy also excludes miscellaneous services such as lodging related to medical care and lists infertility‑related exclusions (see cryopreservation limits) and donor/surrogacy costs.

Gender dysphoria and sexual reassignment related services include specific exclusions. Not covered are cryopreservation, storage, and thawing of reproductive tissue (with the exception rules described elsewhere for short‑term preservation during active infertility treatment), voice modification surgery, and procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons (these are treated as cosmetic). The policy also explicitly excludes reversal of genital surgery.

Transportation is not covered in most circumstances. The policy specifically calls out exclusion of non-covered transport types including transportation by wheelchair van, taxi, and private car. Lodging related to receiving medical services is also listed as not covered.

Additional general exclusions include numerous administrative, convenience, and alternative‑therapy items and charges. Examples are charges for copies of member records, provider charges for missed appointments, chronic care management services, examinations for educational/developmental purposes, electrolysis, exercise classes, medical marijuana, personal emergency response systems, relaxation and massage therapies, TENS units and other neuromuscular stimulators and related supplies, waterproof casts, and inpatient or outpatient weight loss programs and clinics. Services to non‑members and items covered under other government programs (e.g., workers' compensation) are also excluded.

The policy references extensive enumerated non‑covered code lists for Medicaid and INTEGRITY lines of business. These lists include ranges of ICD‑10‑PCS procedure codes, numerous CPT codes (including many T‑, G‑, and specialty procedure codes), and multiple HCPCS codes and code ranges. See the plan’s Medicaid and INTEGRITY non‑covered code listings (chunks 42–55) for the full enumerations.

Under the INTEGRITY designation the policy calls out large blocks of non‑covered procedure and billing codes. Examples highlighted include G0472, G0473, G1000 to G1011, multiple G‑series ranges, selected numeric CPT entries, numerous K‑series and L‑series HCPCS codes, and long ICD‑10‑PCS code ranges (see chunks 54–56 for the detailed lists). Claims billed with codes enumerated in the INTEGRITY non‑covered lists may be denied.

The Commercial section identifies diagnosis, procedure, and billing codes that are non‑covered for Commercial members. Examples include diagnosis codes such as F64.1, diagnosis ranges like L70.0 to L70.9, and multiple CPT/HCPCS examples (e.g., 0012M, 92606, and long HCPCS ranges including Q2033 to Q2039). A detailed Commercial non‑covered code listing is provided in the Commercial code pages and claims using these codes may be denied.

inv-12: Definition note — Cosmetic services considered not medically necessary when they only change appearance without physiological benefit.

DefinitionServices that only change or improve appearance without significantly improving physiological function are considered cosmetic and are not medically necessary.

Scope examplesIncludes procedures such as cervicoplasty, augmentation mammoplasty, liposuction, rhytidectomy, hair transplants, inverted nipple surgery, and cosmetic prosthetic devices.

AuthorityCosmetic surgery defined per American Society of Plastic Surgeons as reshaping normal body structures to improve appearance and self-esteem.

Cosmetic procedures are reiterated as not medically necessary when they primarily change appearance without significantly improving physiological function. The policy excludes a broad list of cosmetic surgeries and procedures (see enumerated examples) and states that such services are not covered unless specifically noted otherwise.

Non-Covered Codes and Code Lists

Medicaid - Non‑Covered Diagnosis/ICD-10ICD-10Not Covered

N46.01-N46.9	Male infertility codes range listed as non-covered
N52.9	Male erectile dysfunction - non-covered per listing
N97.0-N97.9	Female infertility diagnoses - non-covered
202.3, 202.71-202.79, 202.89, 202.9, 204.8	Specified neoplasm/related diagnosis codes listed as non-covered
231.7,231.81-231.9,233.3	Specified benign neoplasm/related codes - non-covered
241.1,241.3,243.7	Thyroid/related diagnoses listed
252.810-252.819,298.810	Specified endocrine/other diagnosis ranges listed

INTEGRITY - Non‑Covered CPT/HCPCS (highlights)mixedNot Covered

0012M,0013M,0018U-0023U,0035U-0039U	Selected CPT temp/proprietary codes flagged as Integrity non-covered
0203T-0244T,0242U-0247U,0249T	T-code ranges from Integrity list
15769,15771-15783,15824-15839	Cosmetic/reconstructive CPT codes emphasized in Integrity list
30430,31647-31651,32994	Surgical CPT examples from Integrity non-covered list

INTEGRITY - Non‑Covered ICD-10-PCS RangesICD-10Not Covered

OOWOXOZ-OOWEXMZ, O1WYXOZ-O1WYXMZ	Example ICD-10-PCS ranges from Integrity list
OCSWOZO-OCSXXZZ, OC9W000-OC9XXZ2	Multiple PCS code blocks flagged as Integrity non-covered
OQWMX4Z-OQWMXKZ, ORW... ranges	Extensive ORW/OSW/OVW series ranges included in Integrity lists

INTEGRITY - Non‑Covered HCPCS (enumerated)HCPCSNot Covered

A0380,A0394,A0432,A4459,A4466	Sample HCPCS codes from Integrity list
C1734,C1749,C1823-C1824,C1839	C-code device examples in Integrity non-covered list
S0215,S0353,S0354,S0596	S‑series HCPCS codes enumerated as non-covered

INTEGRITY - Non‑Covered CPT (additional) CPTNot Covered

4324F-4328F,43284,4330F,4340F	Select CPT/CMS-flagged codes from Integrity non-covered list
55970,55980,58321-58323,58350	Reproductive/gynecologic CPT examples
80300-80377,81313,81410-81414	Molecular/pathology CPT series included

INTEGRITY - Non‑Covered ICD-10 Procedure (continued)ICD-10Not Covered

OQWMX4Z-OQWMXKZ, OQWNX4Z-OQWNXKZ	Additional ICD-10-PCS ranges listed as non-covered by Integrity
OVWSXOZ-OVW8XKZ, OW... series	Further PCS ranges across multiple blocks included in Integrity lists

INTEGRITY - Non‑Covered HCPCS (S/T/V series)HCPCSNot Covered

S0215,S0257,S0285,S0311,S0353	S‑series HCPCS codes included in Integrity non-covered set
T1004,T1040,T2001-T2005,T2048	T-series procedure codes enumerated as non-covered
V2025,V2530,V2531,V2599,V5090	V-series codes shown in Integrity list

INTEGRITY - HCPCS Highlights (callouts)mixed

GO257, G0384, G0410-G0411, G0425-G0428	Selected G-series HCPCS highlighted in Integrity lists
G0472, G0473, G1000-G1011	Additional G-series ranges present in Integrity non-covered lists

INTEGRITY - Notemixed

Reference

Full Integrity non-covered code lists and extended ICD-10-PCS ranges appear on page 18 of the source document (see Coding section)

Commercial - Referenced here for consolidationmixedNot Covered

See Commercial block below

Commercial non-covered codes also consolidated in this section

Commercial - Non‑Covered Diagnosis/ICD-10ICD-10Not Covered

F64.1,F64.2,F64.8,F64.9	Gender dysphoria/sex reassignment diagnosis codes listed as non-covered
L70.0-L70.9	Acne diagnoses range listed
202.3,202.71-Z02.81,252.813,252.819	Selected neoplasm/related and other diagnosis codes
N52.9,287.890,298.810	Additional diagnosis codes flagged non-covered

Commercial - Non‑Covered CPTCPTNot Covered

0012M,0013M,0018U-0023U,0035U-0039U	Selected proprietary/temp CPT codes listed as non-covered
0203T-0244T,0245U-0247U,0249T,0254T,0255T	T/U code ranges from Commercial list
11200-11201,1200F,1400F,15769-15776,15824-15839	Cosmetic/dermatologic and reconstructive CPT examples
17340,17360,17380,17999,19300	Dermatologic/plastic surgery CPT codes listed
31295-31297,31647-31651,31660-31661	ENT/bronchial/surgical CPT examples from Commercial list

Commercial - Non‑Covered HCPCSHCPCSNot Covered

A4336,A4337,A4360,A4459,A4466	Sample A-series HCPCS codes from Commercial list
A4490,A4495,A4500,A4510,A4520	Additional A-series device codes listed as non-covered
C1749,C1823-C1824,C1839	C-code device examples present in Commercial list
E0118,E0160-E0163,E0165	Durable medical equipment HCPCS referenced in Commercial non-covered list

Commercial - Additional/OthermixedNot Covered

92606,92618,92700,93050,93264,93702	Audiology/cardiac/monitoring CPT examples listed as non-covered
98970-98972,99000-99027,99071,99075,99080	Miscellaneous codes (practice expense/professional fees) listed
Q2033-Q2039, Q4114, Q4125, Q4130, Q4142-Q4146	Q-code vaccine/supply HCPCS ranges listed in Commercial non-covered list
S0090,S0207-S0215,S0353,S0354,S1034-S1037	S-series HCPCS codes enumerated as non-covered

Commercial - ICD-10-PCS RangesICD-10Not Covered

O9Q04ZZ,09Q10ZZ-09Q14ZZ,09Q20ZZ-09Q24ZZ	Procedure code blocks listed in Commercial non-covered section
OBW... series, OC... series	Extensive PCS ranges mirrored from Integrity/Medicaid lists present in Commercial list

Commercial - Notemixed

Reference

Full Commercial non-covered code lists appear on page 23 of the source document (see Coding section)

Coding Section Reference Notemixed

Medicaid Non Covered Codes - page 15	See indicated page for full Medicaid non-covered code listings
INTEGRITY Non Covered Codes - page 18	See indicated page for full INTEGRITY non-covered code listings
Commercial Non Covered Codes - page 23	See indicated page for full Commercial non-covered code listings

Cryopreservation duration exceptionmixed

<= 90 days	Short-term cryopreservation may be authorized for certain medical conditions impacting future fertility
> 90 days	Long-term (longer than 90 days) sperm or embryo cryopreservation is not covered unless member is in active infertility treatment

Coding thresholds/notesmixed

No numeric thresholds present

No additional numeric thresholds were provided in the coding lists; refer to full pages for detailed ranges and exceptions

DME Medical Necessity and Repair/Replacement Rules

DME repair/replacement

DME repair, purchase, and replacement claims are covered only when they meet documentation and warranty/rental exclusions described below.

DME repair/replacement exclusions and conditional exceptions: Repair, purchase, or replacement of DME resulting from enrollee abuse is excluded. Repair or replacement of DME items covered under a provider or manufacturer's warranty is excluded. Repair of a rented DME item is excluded. Repair of DME items not covered by Neighborhood is excluded. Exception: replacement or repair of DME that was stolen or destroyed may be considered when documentation is provided (explanation that the item was stolen or destroyed and, if applicable, a police, fire department, or insurance report) plus documentation of continuing medical necessity. Investigational DME (devices lacking FDA approval or investigational devices) is excluded, except investigational services for cancer treatment as required by state regulation.

See chunks 11 and 2 for required documentation and investigational exception; see chunk 32 for network/authorization context.

DME not covered

The following DME and related items are considered non-covered because they are non-essential, cosmetic, or safety-only devices.

DME exclusion node: Non-covered DME and related items include dehumidifiers; orthotic appliances that merely straighten or re-shape (e.g., foot orthotics, cranial banding); devices used specifically as safety items or to affect sports performance; some types of braces including over-the-counter orthotic braces; electric hospital-grade items listed as non-covered; devices and procedures intended to reduce snoring (e.g., laser-assisted uvulopalatoplasty, somnoplasty, snore guards); personal emergency response systems (PERS); TENS units and other neuromuscular stimulators and related supplies when listed as excluded; and long enumerations of HCPCS/CPT supply/device codes that are designated non-covered for the applicable line of business.

See chunk 26 for equipment examples; chunks 3 and 11 for non-DME household items and warranty/rental exclusions; chunks 63 and 66 reference Commercial non-covered code lists.

Topic	Rule / Explanation	Related conditions or exceptions
Rented DME	Repair of a rented DME item is not covered by Neighborhood.	Exceptions for theft/destruction require documentation (explanation of theft/destruction and police/fire/insurance report copy) and demonstration of continuing medical necessity.
Purchase vs. Rental distinction	Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed is not covered except when required documentation is provided.	Documentation required: explanation that the item was stolen or destroyed, and copy of police/fire/insurance report if applicable; must also explain continuing medical necessity.
Repair coverage for rented items	Repair of DME items (including rented items) is not covered.	Repair of items covered under provider or manufacturer warranty is also not covered.
Enrollee abuse	Repair, purchase, or replacement of materials or equipment resulting from enrollee abuse is excluded from coverage.	Documentation of abuse-related damage typically results in denial; exceptions are not specified beyond standard documentation for theft/destruction.

DME item / Category	Coverage status	Notes / examples
Dehumidifiers	not_covered	Listed explicitly as non-covered household equipment.
Orthotic appliances that straighten or re-shape (e.g., foot orthotics, cranial banding)	not_covered	Excluded when used to straighten or reshape a body part.
Devices used specifically as safety items or to affect sports performance	not_covered	Examples include devices intended solely for safety or performance enhancement in sports activities.
Some types of braces (including over-the-counter orthotic braces)	not_covered	Certain braces, including OTC orthotic braces, are excluded.
Electric hospital grade (unspecified)	not_covered	Listed among non-covered devices (term used in source: 'Electric hospital grade').
Devices and procedures intended to reduce snoring (e.g., laser-assisted uvulopalatoplasty, somnoplasty, snore guards)	not_covered	Explicitly excluded examples include laser-assisted uvulopalatoplasty, somnoplasty, and snore guards.

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization and Investigational Exception

Prior authorization is required for many services; investigational or experimental services are generally not payable. Neighborhood will deny requests for drugs or devices that lack FDA approval, treatments that are the subject of Phase I or Phase II clinical trials, or the investigational arm of Phase III trials except where state or federal law requires coverage (for example certain cancer therapies). Document any investigational exception with supporting clinical rationale and evidence of medical necessity.

Investigational/Experimental items (no FDA approval) — prior authorization will not override investigational denial risk
Phase I/II clinical trial treatments and investigational arms of Phase III — not covered unless law requires
Exceptions for cancer therapies per applicable state regulation — document rationale

Billing Rule

Check Non-Covered Code Lists

Providers must consult Neighborhood-specific non-covered code lists before billing. Presence of a code on the plan's Non-Covered CPT, HCPCS, or ICD-10 lists means the service is non-payable regardless of prior authorization.

Medicaid Non-Covered Codes (see plan list)
Commercial Non-Covered Codes (see plan list)
INTEGRITY Non-Covered Codes (see plan list)

Documentation Required

DME Loss / Destruction Documentation

When DME is reported stolen or destroyed, submit documentation to support replacement claims. Repairs or replacements may be denied if due to enrollee abuse, covered by warranty, or if the item was rented.

Provide explanation that the item was stolen or destroyed
Include police, fire department, or insurance report if applicable
Repairs covered under provider or manufacturer warranty are not payable
Repairs of rented DME items are not payable
Claims due to enrollee abuse may be denied

Prior Authorization

Prior Approval / Emergency Documentation

Obtain prior approval for non-network services except true emergencies. For emergency services rendered out-of-network, include documentation showing emergent nature or evidence of prior approval to support coverage.

Services must be rendered by network providers unless emergency or prior approval obtained
For non-network or emergency care, submit clinical documentation demonstrating emergency or prior authorization
Nonconventional settings (spas, wilderness programs, services outside US) generally excluded even if licensed providers deliver them

Billing Rule

HCPCS Non-Covered (Integrity)

Do not bill codes listed on the INTEGRITY non-covered HCPCS/CPT lists. Claims with codes appearing on the Integrity lists are subject to denial and may not be payable even with prior authorization.

Avoid billing INTEGRITY-listed HCPCS and CPT codes (see plan INTEGRITY non-covered lists)
Claims with Integrity non-covered codes may be denied during audit

Key Definitions

inv-43: Cosmetic services definition entry.

Cosmetic services — core definitionProcedures or services that change or improve appearance without significantly improving physiological function.

Clinical noteIncludes reshaping normal structures to improve appearance or self-esteem; services to change appearance are not covered except as described in covered services.

Typical exclusionsExamples include chemical peels, excision of excess skin (e.g., abdominoplasty), dermabrasion, and cosmetic prosthetic devices.

inv-44: Cosmetic Procedure / Cosmetic Surgery definition — procedures that change appearance without physiological benefit.

DefinitionCosmetic Procedure / Cosmetic Surgery: Procedures performed to change or improve appearance without significantly improving physiological function; cosmetic surgery reshapes normal structures to improve appearance and self-esteem.

Included procedures (non-exhaustive)Cervicoplasty, augmentation mammoplasty, mastopexy, brachioplasty, abdominoplasty (except panniculectomy), genioplasty, osteoplasty, liposuction, laser treatments for acne/scars.

Billing implicationAny service, supply, or medication provided to change or improve appearance is not covered unless specifically described as covered in the policy.

inv-45: Surrogate / Gestational carrier definition.

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

Gestational carrierA gestational carrier (gestational surrogate) is a surrogate with no biological connection to the embryo/child.

Coverage noteCosts of surrogacy, including all costs incurred by the surrogate or gestational carrier, are not covered under infertility exclusions.

inv-46: Cosmetic (gender-related) definition — procedures to enhance masculinity/femininity for aesthetic reasons.

DefinitionCosmetic (gender-related): Procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are considered cosmetic.

ExclusionsSuch procedures are excluded unless provided for treatment of gynecomastia or gender dysphoria as specified elsewhere in the policy.

Related non-covered itemsCryopreservation, storage and thawing of reproductive tissue and voice modification surgery are also excluded under sexual reassignment/gender dysphoria treatment provisions.

inv-47: Integrity non-covered — label/definition entry for Integrity non-covered services.

Integrity non-covered — labelNon-Covered Services (INTEGRITY).

Coding implicationExtensive HCPCS/CPT and ICD-10-PCS code lists are enumerated as non-covered under the INTEGRITY designation — providers should avoid billing these codes.

ExamplesSelected INTEGRITY non-covered HCPCS/CPT codes include G0472, G0473, G1000–G1011 and ranges such as G2000–G2015 and K1001–K1006 (see INTEGRITY code lists).

inv-48: Commercial non-covered — label/definition entry for Commercial non-covered services.

Commercial non-covered — labelNon-Covered Services (Commercial).

Coding implicationCommercial section lists diagnosis, CPT and HCPCS codes designated non-covered (e.g., F64.1, L70.0–L70.9, CPT examples such as 0012M, HCPCS A4336).

Prior auth noteCodes listed as non-covered in the Commercial section will not be made covered by prior authorization.

Explicit 'Not Covered' Lines

NOT COVERED: Repair, rental, or replacement of DME is not covered in specified circumstances. The policy excludes repair, purchase, or replacement of DME resulting from enrollee abuse, repair of items covered under a provider or manufacturer warranty, and repair of rented DME items. Investigational DME that lacks FDA approval is excluded. Claims for such items are subject to denial and require the documentation elements described elsewhere if an exception is claimed.

NOT COVERED: Excluded DME and services cannot be approved solely by submission of documentation unless a specific exception applies. For non‑network services, prior approval is required except in emergencies, and providers must submit evidence of network authorization or emergency status to avoid denial. Documentation requirements for theft or destruction of DME are specified elsewhere.

NOT COVERED: Submitters should avoid billing HCPCS/CPT/ICD codes explicitly enumerated as non‑covered under the INTEGRITY and Medicaid sections. Claims billed with codes listed in the non‑covered code lists may be denied; see the detailed code lists for the exact codes and ranges.

NOT COVERED: Services provided in nonconventional settings and non‑medical conveniences are excluded. Examples include care in educational, vocational, recreational, spa, resort, or wilderness camp settings, and charges for services primarily for personal comfort such as telephone, television, or guest services associated with inpatient stays.

NOT COVERED: Administrative or ancillary fees charged by providers are not covered. Examples include additional fees a provider may charge, office infection control charges, and charges for forwarding or mailing copies of member records, charts, or X‑rays.

NOT COVERED: Services and supplies that would be payable under another program or by a third party are excluded, including services covered under workers' compensation, no‑fault auto insurance, or other government programs (except Medicaid where applicable).

NOT COVERED: Personal comfort and lifestyle services are excluded. Examples include personal trainers, exercise classes, and supplies or equipment primarily for comfort rather than medical necessity.

NOT COVERED: Alternative and complementary therapies are listed among exclusions, for example animal therapy, relaxation and massage therapies, and other similar services when not otherwise covered.

NOT COVERED: Certain devices and supplies used for non‑medical or convenience purposes are excluded, including some types of over‑the‑counter braces and devices intended to reduce snoring (e.g., snore guards, laser‑assisted uvulopalatoplasty).

NOT COVERED: Durable medical equipment listed as non‑covered includes items deemed non‑essential or cosmetic/safety related, such as dehumidifiers and electric hospital‑grade items listed in the device sections.

NOT COVERED: Infertility‑related exclusions include experimental infertility procedures, reversal of voluntary sterilization, costs associated with surrogacy, and long‑term cryopreservation (>90 days) unless the member is in active infertility treatment; short‑term cryopreservation (<90 days) may be authorized in specific clinical circumstances.

NOT COVERED: Gender‑affirming cosmetic procedures and other services intended solely to alter appearance are excluded. Exceptions are limited (for example, treatment of gynecomastia or medically necessary care for gender dysphoria where specified).

NOT COVERED: Recreational and non‑medical home items remain excluded, including trampolines, suspension swings, dehumidifiers, and waterproof casts; these items are not considered medically necessary DME.

NOT COVERED: Services for which no charge would be made if the member had no health plan, and services provided to non‑members, are excluded except where covered services explicitly describe otherwise.

NOT COVERED: Health services while on active military duty are excluded under the policy.

NOT COVERED: Items and services required by third parties (for example, a school, employer, or court) that are not otherwise covered by the plan are excluded.

NOT COVERED: The Commercial non‑covered HCPCS code list includes numerous A‑series and other HCPCS examples declared non‑covered for Commercial members (see chunk 63 for the full enumeration, e.g., A9281, A9283, A9285, A9286 and many C‑codes).

NOT COVERED: Additional Commercial non‑covered listings call out multiple L‑series and K‑series HCPCS supply and device codes declared non‑covered (see chunk 66 for the detailed list).

OpenPayer

Coverage exclusions and non-covered services (DME and general)

Non-Covered Services and Exclusions

Non-Covered Codes and Code Lists

DME Medical Necessity and Repair/Replacement Rules

Rental vs Purchase and Specific DME Item Status

Prior Authorization, Documentation, and Denial Risk

Documentation Requirements and Record Retention

Policy Scope and Purpose

Key Definitions

Explicit 'Not Covered' Lines