ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage exclusions and non-covered services

Defines services, items, and situations that Neighborhood Health Plan of Rhode Island does not cover across Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage exclusions and non-covered services

Policy CodePolicy N/A

Change TypeMaterial content updates to cosmetic, infertility, and speech therapy exclusions

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when providing services by non-network providers or for certain infertility-related procedures and document exceptions for DME replacement/theft.

SourceLink

POLICY UPDATE CHANGES

Policy updated to include additional Cosmetic Surgery language for all lines of business and updated infertility language for Medicaid; speech therapy for voice dysphoria added.

Additional codes were added/removed from CPT/HCPC lists at multiple review dates.

Medicaid, INTEGRITY, Commerciallines of business this policy applies to

ExcludedInvestigational/Experimental

ExcludedInfertility services

20+explicit exclusion items

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

externalcoding lists

Coverage Exclusions and Non-Covered Services

Investigational or Experimental Services

Not covered when any of the following investigational/experimental conditions apply:

Investigational/Experimental: Drug or device that lacks FDA approval.

Clinical Trial Exclusion: Requested treatment that is the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials.

Dependency Exclusion: Services delivered in connection with, or required by, an item or service not covered.

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

DME exclusions

DME exclusions — not covered unless documented exception:

Member abuse: Purchase, repair, or replacement resulting from member abuse are excluded.

Stolen or destroyed DME: Purchase, repair, or replacement of items stolen or destroyed are excluded unless documentation provided (explanation of continuing medical necessity, explanation that item was stolen/destroyed, and copy of police/fire/insurance report if applicable).

Warranty or rental exclusions: Repair of Neighborhood non-covered DME items, repair of items covered under provider's or manufacturer's warranty, and repair of rented DME items are excluded.

Cosmetic exclusions

Cosmetic services — not covered except as described in covered services:

General cosmetic exclusion: Procedures or services intended to change or improve appearance without significantly improving physiological function are not covered.

Cosmetic Procedure and Cosmetic Surgery defined per American Society of Plastic Surgeons.

Enumerated cosmetic procedures: Extensive list of excluded cosmetic procedures including (but not limited to) cervicoplasty; chemical peels/exfoliations; augmentation mammoplasty; grafting of autologous fat (except when related to breast cancer/breast reconstruction after mastectomy); excision of excess skin (except panniculectomy); genioplasty; gynecomastia surgery; hair removal and hair transplants; inverted nipple surgery; laser treatment for acne/acne scars; liposuction; osteoplasty; otoplasty; rhinoplasty; rhytidectomy; scar revision regardless of symptoms; sclerotherapy for spider veins; subcutaneous injection of filling material; tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy); testicular prosthesis surgery; and treatment of vitiligo.

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

Dental exclusions

Dental exclusions:

Dental services excluded: All dental services are excluded except emergency dental and limited oral surgery (includes orthodontia exclusion).

Infertility exclusions

Infertility-related services not covered:

General infertility treatments: Infertility treatment including pharmaceuticals, home ovulation prediction kits, and any other service or procedure intended to create a pregnancy are excluded.

Surrogacy and gestational carrier costs: Costs of surrogacy or gestational carrier arrangements (including drugs for implantation, embryo transfer, cryopreservation, use of donor egg, and maternity care when the surrogate is not a member) are excluded.

Cryopreservation limits: Long-term (longer than 90 days) sperm or embryo cryopreservation is excluded unless the member is in active infertility treatment; short-term (less than 90 days) cryopreservation may be authorized for certain medical conditions.

Donor-related exclusions: Costs associated with donor recruitment, compensation/stipend, procurement of frozen donor oocytes, and donor sperm services in the absence of diagnosed male factor infertility are excluded.

Additional exclusions

Other categorical exclusions:

Alternative therapies: Animal therapy, dance therapy, massage therapy, psychodrama, and yoga are excluded.

Home modifications: Permanent home modifications (e.g., permanent lifts affixed to the home, enlarged doorways, ramps, room additions) and related non-covered structural items are excluded.

Miscellaneous exclusions: A broad list of additional excluded items and services including academic testing, concierge fees, dehumidifiers, Lasik, medical marijuana, planned home births, TENS units, wigs (except for alopecia and cancer treatment), weight loss programs, and other items listed in the policy are excluded.

Cosmetic services — Not covered

Services that are cosmetic are not covered except as described elsewhere in covered services.

Cosmetic services exclusion: Any service, supply, or medication to change or improve appearance without significantly improving physiological function is not covered.

Examples enumerated include rhinoplasty, facelifts, liposuction, hair removal, scar revision, tattooing, breast augmentation, and many others.

Infertility services — Not covered or restricted

Infertility-related services that are not covered include the following conditions and items.

Infertility exclusions: Members who do not meet the definition of infertility; experimental infertility procedures; costs of surrogacy/gestational carrier arrangements; donor egg procurement and related drugs and compensation; long-term (>90 days) sperm or embryo cryopreservation unless member is in active infertility treatment; donor sperm services when no diagnosed male factor infertility; services related to conception after voluntary sterilization or unsuccessful sterilization reversal; donor-related costs are not covered.

Short-term (<90 days) cryopreservation may be authorized for certain medical conditions; prior authorization is recommended for drugs for anonymous or designated egg donors directly related to a stimulated ART cycle.

Experimental or Investigational — Not covered

Experimental or investigational services stance

Experimental exclusion: Neighborhood will not pay for treatments that are tests of new treatments or considered experimental/investigational, except where Rhode Island or federal law requires coverage (e.g., certain Lyme disease treatments, new cancer therapies, off-label cancer drug uses).

Transplants of the face and hand are considered experimental and not covered unless required by law.

Network/Setting restrictions — Covered only with network or prior approval

Network and setting restrictions

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

Services provided in nonconventional settings (spas, resorts, educational or recreational settings, wilderness programs, services performed outside the United States/territories) are excluded even if provided by licensed professionals.

Adult Intensive Services — Informational

Informational description of program elements:

AIS services: Adult Intensive Services (AIS) includes emergency/crisis evaluations available 24/7, psychiatric assessment, medication evaluation and management, case management, psychiatric nursing services, and individual, group, and family behavioral health therapy.

Descriptive only — program elements listed.

Not Covered / Excluded Services

The following services are explicitly excluded (not covered) unless otherwise stated by specific medical necessity criteria or prior approval:

Explicit exclusions list: Lodging; over-the-counter contraceptive agents; listed pediatric vision items; reversal of voluntary sterilization; sexual/erectile dysfunction treatment except medically necessary services for organic conditions; sexual reassignment/gender dysphoria-related exclusions (cryopreservation/storage/thawing of reproductive tissue; voice modification surgery; reversal of genital surgery; speech therapy); transportation (chair car, wheelchair van, taxi); services in nonconventional settings; and a broad set of additional administrative and program exclusions (see policy list for full details).

These are categorical exclusions; some items note conditional allowances (e.g., short-term cryopreservation authorization in limited medical conditions).

Circumcisions performed outside of a hospital, day surgery, or a physician's office are not covered.

Scar revision and the other aesthetic procedures listed (for example, cervicoplasty, rhytidectomy, rhinoplasty, liposuction, hair transplants, tattooing/removal, and related items) are explicitly excluded and are not covered regardless of symptoms.

The policy contains wide-ranging exclusions including: adult dental services (routine preventive and restorative services, exams, X-rays, cleanings, extractions, fillings, implants), custodial or non‑skilled care (rest care, day care, long‑term residential care), lodging (not covered even when related to receiving medical services), and numerous personal‑comfort, device, and appliance exclusions (e.g., dehumidifiers, certain orthotic appliances, devices for sport safety, elective refractive eye surgery).

Services, programs, supplies or procedures provided in nonconventional settings (for example, spas/resorts, educational or recreational settings, outward bound/wilderness programs, services performed outside the United States and its territories) are excluded even if provided by licensed professionals.

General categorical exclusions include items such as concierge service fees, medical marijuana, weight‑loss programs, planned home births, and TENS units or other neuromuscular stimulators. Many administrative, convenience, and non‑medical items (e.g., charges for missed appointments, copy fees, personal emergency response systems) are also not covered.

Any service, supply, or medication described as cosmetic—that is, intended to change or improve appearance without significantly improving physiological function—is considered not medically necessary and is not covered, except where another specific covered‑services statement applies.

Procedures performed solely to change or improve appearance without a meaningful physiological benefit (examples include rhinoplasty, facelifts, liposuction, hair removal/transplants, tattooing or tattoo removal, and breast augmentation) are considered not medically necessary and are not covered.

Other explicit exclusions include examples such as lodging; over‑the‑counter contraceptives; certain pediatric vision services and supplies; reversal of voluntary sterilization; and services for sexual or erectile dysfunction (except medically necessary treatment for an organic condition). Services related to sexual reassignment/gender dysphoria (including cryopreservation/storage of reproductive tissue, voice modification surgery, and most related speech therapy) are also listed as not covered except where specifically allowed.

Coding and External Code Grids

External non-covered code gridsmixed

No codes listed

Cryopreservation duration — short-term vs long-term

Authorized short-term cryopreservationShort-term (<= 90 days) cryopreservation of sperm or embryos may be authorized for certain medical conditions that may impact future fertility.

Long-term cryopreservation excluded>90 days (long-term) sperm or embryo cryopreservation is excluded unless the member is in active infertility treatment.

Prior authorization contextAuthorization for short-term cryopreservation is considered for specified medical conditions; long-term storage is considered an excluded infertility service absent active treatment.

Provider Requirements, Prior Authorization, and Denial Risks

Denial Risk

Network / Setting Restrictions

Services must be rendered by network providers unless it is an emergency or prior approval has been received. Any services, programs, supplies or procedures provided in a nonconventional setting are excluded (for example: spas/resorts; educational, vocational, or recreational settings; Outward Bound, wilderness, camp or ranch programs; services performed outside the United States and its territories). This exclusion applies even if provided by licensed personnel (mental health professionals, nutritionists, nurses, physicians). Examples of services that may be excluded if delivered in a nonconventional setting include psychotherapy, ABA services, and nutritional counseling.

Network providers required unless emergency or prior approval obtained.
Nonconventional settings excluded — examples: spas/resorts; educational, vocational, or recreational settings; Outward Bound/wilderness/camp/ranch programs; services outside the U.S. and territories.
Exclusion applies even when provided by licensed clinicians (e.g., mental health professionals, nutritionists, nurses, physicians).

Background and Scope Notes

This document lists a range of categorical exclusions including investigational/experimental items, cosmetic services, exclusions for misuse or unsupported replacement of durable medical equipment, and detailed infertility‑related exclusions (including donor and surrogacy costs and limits on cryopreservation). These exclusions define services that Neighborhood Health Plan of Rhode Island does not cover across applicable lines of business.

Key Definitions

Cosmetic Procedure / Cosmetic Surgery

Definition — Cosmetic ProcedureProcedures or services that change or improve appearance without significantly improving physiological function.

Definition — Cosmetic SurgeryPer the American Society of Plastic Surgeons: performed to reshape normal structures of the body in order to improve the patient's appearance and self‑esteem.

Coverage stanceExcept as described in covered services, any service, supply, or medication to change or improve appearance is not covered.

Surrogate / Gestational carrier — policy notes

Surrogate / Gestational carrier noteThe policy describes surrogate and gestational carrier arrangements in infertility exclusions and clarifies related cost exclusions (e.g., drugs, implantation, transfer, cryopreservation, maternity care).

Surrogacy costs excluded

Document History and Changes

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage exclusions and non-covered services

Policy CodePolicy N/A

Change TypeMaterial content updates to cosmetic, infertility, and speech therapy exclusions

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization when providing services by non-network providers or for certain infertility-related procedures and document exceptions for DME replacement/theft.

SourceLink

On This Page

Prior authorization is recommended for drugs for anonymous or designated egg donors directly related to a stimulated ART cycle when applicable.

Sterilization-related exclusion: Infertility services necessary for conception after voluntary sterilization or following unsuccessful reversal of voluntary sterilization are excluded.

Prior Approval Required for Non‑Network Care

Prior approval is required for services delivered by non-network providers when the care is not an emergency. Providers should obtain authorization before rendering services to avoid claim denials.

Prior approval required for non-network services when not an emergency.
Failure to obtain prior approval may result in denial of payment.

Denial Risk

Circumcision Setting Restriction

Circumcisions will not be covered if they are performed in any setting other than a hospital, day surgery, or a physician's office.

Circumcision only covered when performed in: hospital, day surgery, or physician office.
Circumcisions performed in other settings are not covered and may be denied.

Denial Risk

Lodging Not Covered

Claims for lodging will be denied, even when related to receiving medical services. Providers should not bill lodging charges to Neighborhood for members.

Lodging is not covered in any circumstance, including when related to medical care.
Do not submit lodging charges as part of claims to Neighborhood.

Documentation Required

DME Documentation and Denial Risks

Purchase, repair, or replacement of durable medical equipment (DME) may be denied for certain conditions. Documentation is required when denial risks exist (for example, requests related to theft or destruction). Repairs for items covered under a provider's or manufacturer's warranty, rented DME items, or DME resulting from member abuse are not covered.

DME denied for member abuse-related damage.
DME stolen/destroyed — provide explanation of continuing medical necessity, explanation of theft/destruction, and copy of police/fire/insurance report when applicable to avoid denial.
Repairs of Neighborhood non-covered DME items, items under warranty, and rented DME are not covered.

Denial Risk

Investigational / Experimental Services

Investigational or experimental services, including drugs or devices lacking FDA approval, treatments that are part of Phase I/II trials or investigational arms of Phase III trials, and services delivered in connection with non-covered items, will be denied as investigational. Exception: routine services associated with investigational cancer treatments may be covered per state regulation.

Drugs or devices without FDA approval are considered investigational.
Treatments in Phase I/II clinical trials or investigational arms of Phase III trials are investigational and will be denied.
Routine services tied to investigational cancer treatments may be covered per applicable state regulations.

Prior Authorization

Infertility Services — Exclusions and Prior Authorization Notes

Infertility-related services and procedures are subject to multiple exclusions and prior authorization considerations. Donor recruitment, compensation, costs for surrogacy or gestational carriers, long-term (>90 days) cryopreservation (unless member in active infertility treatment), and services for members who do not meet the definition of infertility are not covered. Prior authorization is recommended for drugs for anonymous or designated egg donors directly related to a stimulated ART cycle; short-term (<90 days) cryopreservation may be authorized for certain medical conditions.

Surrogacy and gestational carrier costs (including drugs for implantation, embryo transfer, cryopreservation, maternity care for non-member surrogates) are not covered.
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.
Donor recruitment, compensation/stipend, and medications for donors are not covered.
Donor sperm and related lab services are not covered in absence of diagnosed male factor infertility in the partner.
Prior authorization is recommended for donor egg drug costs directly related to a stimulated ART cycle when the member is not the sole recipient.

Denial Risk

Cosmetic Services Exclusions

Cosmetic procedures and related supplies are excluded and may be denied. This includes a broad list of aesthetic surgeries, procedures, and services (e.g., rhinoplasty, facelifts, liposuction, hair transplants, scar revision, tattooing/tattoo removal, removal of skin tags), as well as related hospital and professional charges when the primary service is cosmetic.

Extensive list of cosmetic exclusions: cervicoplasty; chemical exfoliations/peels; augmentation mammoplasty/mastopexy; excision of excess skin (except panniculectomy); genioplasty; fat grafting from liposuction (except breast reconstruction post-mastectomy); gynecomastia surgery; hair removal/transplants; inverted nipple surgery; laser treatment for acne/scars; liposuction; osteoplasty; otoplasty; rhinoplasty; rhytidectomy; scalp hair prostheses/wigs for certain alopecia conditions; scar revision; sclerotherapy for spider veins; subcutaneous filler injections; tattooing/tattoo removal (except nipple/areola tattooing related to mastectomy); testicular prosthesis; treatment of vitiligo.

Billing Rule

Coding, Billing, and Documentation Guidance

Claims are subject to coding and documentation requirements. Providers should follow Neighborhood's billing and coding guidelines and the non-covered code grids; claim payment is subject to member eligibility, contract terms, coding edits, authorization policies, and applicable regulations.

Refer to Neighborhood non-covered CPT, HCPCS, ICD-10, and Modifier grids at: https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/
Policy information is informational and not a guarantee of reimbursement; all claims remain subject to audits, edits, and contractual rules.

Costs of surrogacy/gestational carrier arrangements, including drugs for implantation, embryo transfer, cryopreservation, use of donor egg, and maternity care for a non-member surrogate, are excluded.

Donor-related exclusionsCosts associated with donor recruitment, compensation, procurement of frozen donor oocytes, and donor sperm services (absent diagnosed male factor infertility) are excluded.

Surrogate — carries and delivers a child for another

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

Associated cost exclusionsThe costs to achieve a pregnancy as a surrogate (drugs for implantation, embryo transfer, cryopreservation, and maternity care if the surrogate is not a member) are excluded.

Relation to donor servicesUse of donor egg and related donor costs when involving a surrogate are explicitly listed among excluded infertility services.

Gestational carrier — surrogate with no biological connection

Gestational carrier — definitionA gestational carrier is a surrogate with no biological connection to the embryo/child.

Policy implicationUse of a gestational carrier and associated costs (including donor egg use and drugs for implantation, embryo transfer, cryopreservation, and maternity care for a non-member) are excluded under infertility services.

Distinction from surrogate with biological connectionThe policy distinguishes gestational carriers as having no biological connection, as noted in infertility service exclusions and examples.