CurrentNeighborhood Health Plan of Rhode IslandPolicy 000448

Non-Covered Services

This policy defines Neighborhood Health Plan of Rhode Island's non-covered services and applies to all lines of business and members served by the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services

Policy CodePolicy 000448

Change TypeNo material changes

Effective DateJan 1, 2017

Next Review DateN/A

Key ActionObtain prior authorization for short-term (<90 days) cryopreservation and consult non-covered code lists before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

applies to all linesScope

000448Identifier

multiple exclusionsContent type

multipleExplicit exclusion categories

2Non-covered code lists

Non-covered Services and Exclusions

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General Non-Covered Services

Services and items listed below are not covered by Neighborhood unless otherwise specified in covered services or required by law.

Alternative and Complementary Medicine: Alternative medicine services, supplies, or procedures (including naturopathic, holistic, functional health) are not covered. Biofeedback is not covered except for treatment of urinary incontinence. Hypnotherapy is not covered.

Cosmetic Services: Any service, supply, or medication to change or improve appearance is not covered except as described in covered services. Examples include cervicoplasty; chemical peels/abrasions/dermabrasion; sclerotherapy for spider veins; subcutaneous injections for filling; breast augmentation/contouring procedures; testicular prosthesis; scar revision; hair removal (including electrolysis); excision of excess skin (e.g., brachioplasty, abdominoplasty) except panniculectomy as described elsewhere; hair transplants; vitiligo treatment; inverted nipple surgery; gynecomastia surgery; laser treatment for acne; liposuction; rhinoplasty; tattooing/tattoo removal (except nipple/areola related to mastectomy); otoplasty; rhytidectomy (facelift); and other listed cosmetic procedures and prosthetic devices.

Custodial Care: Custodial care, rest care, or non-skilled care in any facility (including convalescent homes, nursing homes, residential facilities) is not covered.

Dental Services: Preventive and restorative dental services, treatments, and supplies are not covered. Orthodontia and all dental services are excluded except emergency dental and limited oral surgery.

Vision/Refractive Surgery: Refractive eye surgery (including radial keratotomy) and contact lens fittings are not covered except as described in covered services; pediatric vision exclusions include other non-covered vision materials and services listed.

Infertility and Reproductive Services: Infertility treatment is not covered when member does not meet the definition of infertility, for experimental procedures, costs of surrogacy (including drugs for implantation, embryo transfer, and cryopreservation), donor recruitment/compensation, long-term (>90 days) cryopreservation unless in active treatment (note: short-term <90 days may be authorized with prior authorization for certain medical conditions), infertility services after voluntary sterilization or failed reversal, donor sperm in absence of male factor infertility, drugs for egg donors related to stimulated ART unless member is sole recipient, costs for maternity care if surrogate is not a member, use of donor egg and gestational carrier, and related exclusions.

Prior authorization required or recommended in specified scenarios (see policy).

Home Births/Doula: Costs associated with services provided by a doula for home births and planned home births are not covered.

Human Organ Transplants: Transplants are not covered unless specified by CMS or applicable coverage rules.

Lodging, even when related to receiving medical services, is not covered.

Network/Setting Restrictions: Services must be rendered by network providers unless it is an emergency or prior approval has been received. Services, programs, supplies, or procedures provided in non-conventional settings (e.g., spas/resorts, outward bound/wilderness programs, educational/vocational/recreational settings, services performed outside the United States and its territories) are excluded.

COVERAGE CRITERIA

Exclusions and restrictions — items and services listed below are explicitly excluded or restricted under this policy unless an exception is stated.

Lodging is not covered even when related to receiving any medical service.

Network and Setting Restrictions: Services must be rendered by network providers unless it is an emergency or prior approval is obtained. Services provided in non-conventional settings (e.g., spas/resorts; outward bound, wilderness, camp or ranch programs; educational, vocational, or recreational settings; services performed outside the U.S. and its territories) are excluded.

Surrogacy-related Costs: All costs of surrogacy or gestational carrier processes are excluded, including drugs for implantation, embryo transfer, and cryopreservation of embryos; a gestational carrier is defined as a surrogate with no biological connection to the embryo.

Third-party and Non-member Services: Services, supplies, or medications required by a third party (employer, school, court, etc.) or provided to non-members are excluded.

Neighborhood excludes cosmetic services and procedures intended to change or improve appearance unless specifically described as covered elsewhere in the plan. Examples include, but are not limited to: cervicoplasty; chemical peels/dermabrasion; sclerotherapy for spider veins; subcutaneous injectable fillers; augmentation mammoplasty and mastopexy; testicular prosthesis; scar revision; hair removal (including electrolysis); excision of excess skin or subcutaneous tissue (e.g., brachioplasty, abdominoplasty) except panniculectomy where noted; hair transplants; vitiligo treatment; inverted nipple surgery; gynecomastia surgery; laser treatment for acne; liposuction; rhinoplasty; tattooing and tattoo removal (except nipple/areola tattooing post-mastectomy); otoplasty; and rhytidectomy (facelift).

Neighborhood will not pay for treatments that are tests of treatments (procedures performed solely to evaluate or try an unproven therapy). This prohibition does not apply to services that meet coverage conditions under Rhode Island or federal law, including certain new therapies for cancer, treatment of Lyme disease, or off‑label uses of prescription drugs for cancer when coverage criteria are met.

The policy lists explicit exclusions and restrictions. Lodging related to receiving medical services is not covered. Services must be provided by network providers unless it is an emergency or prior approval has been obtained; services performed in non-conventional settings (for example, spas/resorts, wilderness programs, educational/vocational/recreational settings, or services performed outside the U.S. and territories) are excluded. Surrogacy-related costs (all costs incurred by a surrogate or gestational carrier, including drugs for implantation, embryo transfer and cryopreservation) are excluded. The policy also excludes various non‑DME household items (e.g., air conditioners, air purifiers/HEPA filters, floor mats, trampolines, suspension swings, car seats, and certain specialty diet foods) and a broad set of cosmetic procedures and devices as listed elsewhere.

Cosmetic surgery and cosmetic prosthetic devices are excluded. Examples include body piercing; breast implant removal; tattoos or tattoo removal; tongue splitting or repair; and breast augmentation (except post-mastectomy reconstruction/repair as specifically allowed). Cosmetic prosthetic devices are similarly excluded.

Neighborhood excludes orthodontia and all dental services except for emergency dental care and limited oral surgery. Preventive and restorative dental services, treatments and supplies are not covered under this policy.

Infertility-related services are broadly excluded. Specific examples include home ovulation prediction kits, services for couples in which one partner has had a previous sterilization procedure (with or without reversal), and other services or procedures intended to create a pregnancy. The policy also states that costs associated with surrogacy and gestational carrier processes are excluded, including drugs for implantation, embryo transfer, and cryopreservation of embryos.

Additional exclusions (not an exhaustive list) include: academic performance testing; altered auditory feedback devices; acupuncture; cord blood banking; diagnostic tests performed solely to evaluate the need for a non-covered service; educational testing and training programs; drugs for sexual or erectile dysfunction; electrosleep therapy; intravenous histamine therapy; health club memberships; LASIK surgery; planned home births; sex reassignment surgery; sperm banking; thermogenic therapy; transcendental meditation; various alternative therapies such as animal therapy, psychodrama, and dance therapy; and multiple non‑DME household items such as air conditioners, air purifiers/HEPA filters, floor mats, trampolines, suspension swings, car seats, and certain specialty diet foods.

Services primarily intended for cosmetic purposes are considered not medically necessary and are not covered. This policy provides a detailed list of cosmetic procedures and devices that fall into that category; claims for those services will be denied as non‑covered unless a specific exception is documented in covered services.

Services provided for educational, developmental, vocational or recreational purposes are excluded. Additionally, diagnostic tests performed solely to evaluate the need for a non-covered service are listed as excluded and therefore considered not medically necessary under this policy.

Codes and External Non-covered Lists

Non-covered code lists (reference links)mixed

No codes listed

Provider Requirements, Authorization, and Documentation

Billing Rule

Check non‑covered code lists

Check the plan’s non-covered code lists before billing. Claims for CPT, HCPCS, or ICD-10 codes that appear on the Health Benefits Exchange Plan Non-Covered Codes or the Medicaid Managed Care Plan Non-Covered Codes lists are subject to denial and should not be submitted without prior confirmation of coverage.

Reference the plan-specific non-covered code lists (Exchange and Medicaid) before filing claims.

Denial Risk

Denial risk for excluded services

Claims for items and services explicitly listed as exclusions (for example: cosmetic devices/procedures, dental services except emergency/limited oral surgery, infertility-related treatments, LASIK, wigs except for alopecia/cancer) are at high risk of denial. Do not bill Neighborhood for excluded services unless prior written approval or a documented exception applies.

Excluded examples: cosmetic prosthetic devices; most dental care; infertility services (see infertility exclusions); LASIK; non‑covered wigs.

Documentation Required

DME replacement and repair documentation requirements

For DME purchases, repairs, or replacements due to theft, destruction, or alleged abuse, submit supporting documentation with the claim. Required documentation includes an explanation of continuing medical necessity and, when applicable, a copy of a police, fire department, or insurance report describing the theft or destruction. Repairs covered under a provider’s or manufacturer’s warranty, or repairs of rented DME, are not payable by Neighborhood.

Provide explanation of continuing medical necessity.
If item stolen/destroyed, include copy of police/fire/insurance report when available.
Warrantied repairs and repairs of rented DME are not covered.

Documentation Required

Documentation and audit — retain supporting records

All services billed to Neighborhood are subject to coding, documentation review, and post‑payment audit. Providers must retain and make available supporting medical records, receipts, and authorization documentation on request. Payments may be adjusted or recovered if documentation does not support the billed services or if coverage rules were not met.

Maintain complete medical records and documentation supporting medical necessity and prior authorizations.
Claims may be audited and are subject to coding and payment edits.

Step Therapy

Step therapy not applicable

No step therapy requirements are specified in this section.

Key Definitions

inv-28: Costs of surrogacy — definition and included examples

DefinitionAll costs incurred by a fertile woman to achieve a pregnancy as a surrogate or gestational carrier for an infertile member.

Includes—medicationsCosts for drugs needed for implantation.

Includes—proceduresCosts for embryo transfer (including surgical implantation).

Includes—embryo servicesCosts for cryopreservation of embryos.

Carrier definitionA gestational carrier is a surrogate with no biological connection to the embryo; a surrogate may carry and deliver a child for another via artificial insemination or surgical implantation.

inv-29: Dental Care — preventive and restorative services excluded

Scope of exclusionPreventive and restorative dental services, treatments, and supplies are not covered.

OrthodontiaOrthodontia is excluded (see broader exclusions list).

Emergency exceptionEmergency dental and limited oral surgery are exceptions to the exclusion (covered).

Non-conventional settings noteServices provided in non-conventional settings remain subject to network/setting exclusions and may be denied even if dental in nature.

inv-30: Surrogacy / Gestational carrier costs — detailed examples

Drugs for implantationCosts for prescription drugs required for implantation of an embryo are excluded.

Embryo transfer proceduresCosts associated with embryo transfer, including surgical implantation, are excluded.

CryopreservationCosts for cryopreservation (storage) of embryos are excluded.

Surrogate/gestational carrier servicesAll services and processes incurred by the surrogate or gestational carrier to achieve pregnancy are excluded, regardless of provider licensure.

Relationship to memberExclusion applies when a fertile woman acts as surrogate or gestational carrier for an infertile member.

Policy Background

Background: This document serves as Neighborhood Health Plan of Rhode Island's exclusions and non‑covered services list to identify services, supplies, procedures and settings that will not be paid by the plan. It applies to all lines of business and members served by the plan and covers areas including cosmetic procedures, alternative and complementary medicine, custodial care, dental and vision exclusions, infertility and surrogacy exclusions, lodging, non‑network or non‑conventional setting restrictions, and numerous other specific items and services listed throughout the policy.

Policy Revision History

2017-01-01published

Policy 000448 published and became effective; document marks the policy effective date as 01/01/2017.

as writtendisclaimer_updateLatest

Guideline reimbursement disclaimer and policy audit/coverage language included clarifying that the guideline is informational only and not a guarantee of reimbursement.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services

Policy CodePolicy 000448

Change TypeNo material changes

Effective DateJan 1, 2017

Next Review DateN/A

Key ActionObtain prior authorization for short-term (<90 days) cryopreservation and consult non-covered code lists before submitting claims.

SourceLink

On This Page

Care Covered by Other Programs: Care covered under federal, state, or local legislation (e.g., workers' compensation, no-fault auto insurance) or military service-related disabilities when other coverage is available is excluded.

Contraception/Sterilization and Gender Procedures: Medical or surgical procedures for sexual reassignment, reversal of voluntary sterilization, and over-the-counter contraceptive agents are not covered.

Transportation by chair car, wheelchair van, or taxi is excluded.

Common Miscellaneous Exclusions: Provider missed appointment charges; charges for copies/mailing of records; electrolysis; exercise classes; examinations/evaluations for educational or developmental purposes (including vocational rehabilitation and retraining); office infection control charges; personal trainer; relaxation and massage therapies; weight loss programs and clinics; and related items are excluded.

Investigational/Experimental Services: Drugs or devices lacking FDA approval and treatments that are the subject of Phase I/II clinical trials or the investigational arm of Phase III clinical trials are excluded. Exception: investigational/experimental services for cancer treatment are covered per state regulation.

DME Exclusions and Documentation: Purchase, repair, or replacement of DME due to enrollee abuse is excluded. Replacement of stolen or destroyed DME requires documentation (explanation of continuing medical necessity, copy of police/fire/insurance report if applicable, and explanation that the item was stolen or destroyed). Repair of rented items and items covered under warranty are not covered.

Non-DME Durable/Other Non-covered Items: Items such as air conditioners, air purifiers/HEPA filters, floor mats, trampolines/mini trampolines, hypoallergenic pillows/bedding, suspension swings, car seats, and food products for specialty diets are excluded.

Cosmetic Procedures and Devices: Cosmetic prosthetic devices and cosmetic surgery (including body piercing; breast implant removal; tattoos or tattoo removal; tongue splitting/repair; breast augmentation except post-mastectomy repair) are excluded.

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

Alternative Therapies: Animal therapy, psychodrama, dance therapy and similar alternative therapies are excluded.