CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Covered Services Payment Policy – Archive 13

Defines services, supplies, devices, and procedures that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business; includes investigational/experimental exclusions, DME exclusions, cosmetic exclusions, infertility, dental, alternative therapies, and other general exclusions. Provides links to coding grids for plan-specific non-covered CPT/HCPCS/ICD-10/Modifier lists.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy – Archive 13

Policy CodePolicy N/A

Change TypeRevised (code list and exclusions updates)

Effective DateFeb 28, 2017

Next Review Date

Key ActionFollow the plan-specific non-covered CPT/HCPCS/ICD-10/Modifier grids at the provided external link and provide required documentation (e.g., police/fire/insurance report) for replacement of stolen or destroyed DME.

SourceLink

POLICY UPDATE CHANGES

03/11/24 Annual Policy Review Date. Policy updated: additional codes added/removed from CPT/HCPC list, added surrogate language to Medicaid section.

11/28/23 Policy updated: additional codes added/removed from CPT/HCPC list.

09/05/23 Added services to Additional Coverage Exclusions for all LOB; removed abortion services exclusion for all LOB; removed vitiligo from Integrity.

03/29/23 Added Concierge Services for all LOB; converted CPTs/HCPCs/ICD-10 and Modifiers to external link; added GC modifier to Commercial.

MultipleExcluded Service Categories

ExtensiveNon-covered line items

Coverage Summary

Scope: Neighborhood Health Plan of Rhode Island coverage exclusions for services, supplies, devices, and procedures across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. This archival payment policy enumerates numerous non-covered items and services and is informational only and not exhaustive. It references external plan-specific coding grids for CPT/HCPCS/ICD-10/Modifier non-covered lists maintained on the plan website.

This policy documents Neighborhood's non-covered services and exclusions and notes that claim payments remain subject to benefit coverage, member eligibility, coding and documentation rules, authorizations, provider agreements, and state/federal regulations. Document history records code list updates and substantive changes (e.g., added surrogate language to Medicaid and periodic CPT/HCPCS code updates).

Policy key facts

Effective date2017-02-28

Last review2024-03-11

Has material changeYes — document history notes multiple material updates (e.g., 03/11/24, 09/05/23, 03/29/23)

Excluded Service CategoriesMultiple categories (cosmetic, DME, infertility, dental, alternative therapies, etc.)

Non-covered line itemsExtensive list (many specific exclusions detailed in policy)

Code-level exclusions maintainedExternal non-covered CPT/HCPCS/ICD-10/Modifier grids — see plan link

Medical-Necessity Criteria & Exclusions

General Non-Covered Services

Services and items listed are not covered unless an exception is stated elsewhere:

Investigational/Experimental: Drug or device that lacks FDA approval (investigational/experimental).
Clinical Trials: Requested treatment that is the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials.
Connected to Non-covered Items: Services which are delivered in connection with, or required by, an item or service not covered.
Cancer Treatment Exception:

Coding

Plan-specific non-covered code grids (external link)mixedNot Covered

External link

https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/ - contains CPT/HCPCS/ICD-10/Modifier non-covered lists (not embedded in this document)

Provider Actions

Documentation Required

Documentation for stolen/destroyed DME

For replacement of DME that was stolen or destroyed, providers must submit: 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 when applicable.

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

Prior Authorization

Prior authorization recommended for certain donor egg/drug services

Prior authorization is recommended for drugs for anonymous or designated egg donors and may be required for certain infertility-related services such as procurement of donor eggs and related drug therapies.

Definitions

Cosmetic Procedure: Procedures or services that change or improve appearance without significantly improving physiological function.

Cosmetic Surgery: As defined by the American Society of Plastic Surgeons, surgery "performed to reshape normal structures of the body in order to improve the patient's appearance and self‑esteem."

Surrogate: A person who carries and delivers a child for another either through artificial insemination or surgical implantation of an embryo.

Gestational carrier: A surrogate with no biological connection to the embryo/child.

Revision History

2017-02-28effective

Policy effective date (document history lists 02/28/17 as policy effective date).

03/29/23revised

Added Concierge Services to Additional Coverage Exclusions for all lines of business; converted CPT/HCPCS/ICD-10/Modifier code lists to an external coding grid link; added GC modifier to Commercial.

09/05/23revised

Substantive changes to Additional Coverage Exclusions across lines of business: services added to exclusions, abortion services exclusion removed for all lines of business, and vitiligo removed from Integrity.

DME (Durable Medical Equipment) Exclusions

DME items not covered when any of the following apply:

Abuse-related Damage: Purchase, repair, or replacement of materials or equipment resulting from member abuse.
Stolen or Destroyed Items: Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed, unless documentation is provided including explanation of continuing medical necessity, explanation that item was stolen/destroyed, and copy of police/fire/insurance report if applicable.
Providers must supply required documentation for stolen/destroyed DME.
Repair of Non-covered DME: Repair of Neighborhood non-covered DME items.
Warranty Repairs: Repair of DME items covered under the provider's or manufacturer's warranty.
Rented Item Repairs: Repair of a rented DME item.
Electric Hospital Grade Breast Pump Purchases: Electric hospital grade breast pump purchases (listed under Devices, Appliances and Prosthetics) are not covered.

Cosmetic Services Exclusions

Cosmetic procedures and supplies that change or improve appearance without significantly improving physiological function are not covered, except as described in covered services:

Cervicoplasty (neck plastic surgery).
Chemical Peels and Dermabrasion: Chemical exfoliations, peels, abrasions, dermabrasions or planing for acne, scarring, wrinkling, sun damage or other conditions.
Breast Procedures: Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, and correction of congenital breast asymmetry (modifying size, contour, elevation).
Cosmetic Prosthetic Devices: Cosmetic prosthetic devices.
Related Charges: Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons/assistant surgeons/attending physicians and other incidental services related to cosmetic surgery.
Excision of Excess Skin: Excision of excess skin or subcutaneous tissue including brachioplasty or abdominoplasty (except panniculectomy).
Genioplasty.
Gynecomastia Surgery: Gynecomastia surgery, including mastectomy and reduction mammoplasty.
Hair Removal and Transplants: Hair removal including electrolysis/epilation and hair transplants.
Inverted Nipple Surgery: Inverted nipple surgery.
Laser Treatment for Acne: Laser treatment for acne and acne scars.
Liposuction/suction assisted lipectomy.
Concurrent Medically Necessary Procedures: Medically necessary procedures performed at the same time as a cosmetic procedure are excluded unless otherwise covered.
Osteoplasty (facial bone reduction).
Otoplasty (ear plastic surgery).
Skin Tag Removal: Removal or destruction of skin tags; repeated cauterizations or electrofulguration to remove growths.
Rhinoplasty.
Rhytidectomy (facelift).
Scalp Hair Prostheses and Wigs: Scalp hair prostheses made specifically for an individual, or a wig, for hair loss due to alopecia areata, alopecia totalis, or permanent loss due to injury are listed as non-covered here but exceptions for alopecia and cancer treatment exist elsewhere.
Scar Revision: Scar revision, regardless of symptoms.
Sclerotherapy/treatment for spider veins.
Filler Injections: Subcutaneous injection of filling material.
Tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy).
Testicular Prosthesis: Testicular prosthesis surgery.
Vitiligo Treatment: Treatment of vitiligo (white patches on skin).

Infertility Exclusions

Infertility-related services and procedures that are not covered:

Home Ovulation Kits: Home ovulation prediction kits are not covered.
Services to Create Pregnancy: Any service or procedure intended to create a pregnancy is excluded (general exclusion).
Sterilization-related Services: Services for couples in which one partner has had previous sterilization, with or without reversal, and infertility services necessary for conception after voluntary sterilization or unsuccessful reversal are not covered.
Surrogacy and Gestational Carrier Costs: Costs of surrogacy/gestational carrier including drugs for implantation, embryo transfer, cryopreservation, use of donor egg, and costs for maternity care if surrogate is not a member; donor recruitment/compensation also excluded.
Cryopreservation Rules: Long-term (>90 days) sperm or embryo cryopreservation is not covered unless member is in active infertility treatment; short-term (<90 days) may be authorized for certain medical conditions.
Donor Gamete Costs: Donor sperm and associated lab services are not covered absent diagnosed male factor infertility in the partner; procurement of frozen donor oocytes and drugs for anonymous/designated egg donors are not covered unless member is sole recipient of donor's eggs (prior authorization recommended).
Prior authorization is recommended for certain donor egg/drug services.

Other Specific Exclusions

Additional listed exclusions (non-exhaustive):

Academic and Educational Testing: Academic performance testing; educational test and training programs; examinations/evaluations for educational/developmental purposes are not covered.
Respite/Custodial Care: Adult respite care (except hospice) and custodial care/rest care/day care/non-skilled care in any facility are not covered.
Home Items and Devices: Air conditioners, air cleaners, purifiers, HEPA filters, dehumidifiers, floor mats, hypoallergenic pillows/bedding, home modification items (decks, permanent lifts, ramps, grab bars, etc.) and other personal comfort devices are not covered.
Concierge Services: Concierge services fee or retainer is not covered.
Drugs for Sexual Dysfunction: Drugs or devices used to treat sexual or erectile dysfunction are not covered except medically necessary services for organic conditions.
LASIK and Medical Marijuana: Lasik surgery and medical marijuana are not covered.
Wig Exception: Wigs are listed as non-covered but exception exists for alopecia and cancer treatment as noted elsewhere.
Experimental Transplants and Related: Experimental transplant procedures (e.g., face and hand transplants) are not covered; services/supplies related to excluded transplant procedures and donor expenses not directly related to transplant are not covered.
Lodging is not covered even when related to receiving medical services.
Network Restrictions and Nonconventional Settings: Services must be by network providers unless emergency or prior approval received; services in nonconventional settings (spas/resorts, educational/vocational/recreational settings, outward bound/wilderness programs, services outside US/territories) are excluded.
Pediatric Vision Exclusions: Pediatric vision exclusions include replacement of lost/stolen eyewear, non-prescription lenses, two pairs instead of bifocals, special lens designs/coatings not described as covered, and insurance of contact lenses.
Reversal of Sterilization: Reversal of voluntary sterilization (medical or surgical) is not covered.
Gender Dysphoria Related Exclusions: Cryopreservation/storage/thawing of reproductive tissue, procedures to enhance masculinity/femininity or alter contours for aesthetic reasons (except gynecomastia and gender dysphoria treatment), voice modification surgery, and reversal of genital surgery are excluded.
Transportation Exclusions: Transportation exclusions include chair car, wheelchair van, taxi, and similar transport.
Miscellaneous Items: Any provider charges for missing an appointment, charges for copies of records, office infection control charges, weight loss programs/clinics (inpatient/outpatient), TENS units or other neuromuscular stimulators and related supplies, and many other listed miscellaneous items are not covered.
Electric Hospital Grade Breast Pump Purchases: Electric hospital grade breast pump purchases are also listed as non-covered under devices/appliances/prosthetics and in additional exclusions.