CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-Covered Services Payment Policy – Archive 17

Defines services, items, and circumstances that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Provides examples and categories of non-covered services, investigational items, DME exclusions, cosmetic procedures, infertility services, and other general exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy – Archive 17

Policy CodePolicy N/A

Change TypeRevised (material and administrative updates)

Effective DateFeb 28, 2017

Next Review Date

Key ActionFollow the plan-specific external Non-Covered CPT/HCPCS/ICD-10/Modifier grids linked in the policy and obtain prior authorization where recommended or required.

SourceLink

POLICY UPDATE CHANGES

02/14/25: Policy updated; additional codes added/removed from CPT/HCPC and diagnosis lists.

12/11/24: Annual policy review; cosmetic surgery language updated for all lines of business; infertility language updated for Medicaid; speech therapy for voice dysphoria added.

09/18/24, 07/01/24, 03/11/24, 11/28/23 and prior dates: Policy updated with additional codes added/removed from CPT/HCPC lists and surrogate language added to Medicaid.

03/29/23: Added Concierge Services to Additional Coverage Exclusions and converted code lists to external grid; added GC modifier to Commercial.

MultipleExcluded Service Categories

ExternalNon-covered codes referenced externally

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Medicaid/INTEGRITY/CommercialLines of Business

Coverage Summary

Scope: Defines services, items, and circumstances that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines of business. Effective date: 2017-02-28. Last review: 2025-02-14.

Policy stance: Neighborhood considers cosmetic procedures and related services to be non-covered (coverage stance: not_covered_cosmetic). This payment policy lists examples and categories of non-covered services and clarifies that exclusions apply across the plan lines of business noted above; the lists are illustrative and not exhaustive.

Key Policy Facts

Lines of BusinessMedicaid (excluding EFP), INTEGRITY, Commercial

Effective Date2017-02-28

Last Review Date2025-02-14

Policy StatusCURRENT

Coverage StanceNot covered — cosmetic and other exclusions (policy lists non-covered services/categories)

External code grid link notePlan-specific non-covered CPT/HCPCS/ICD-10/Modifier lists available at https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/; code lists maintained externally and updated periodically.

Medical-Necessity Criteria & Exclusions

General Non-Coverage Principles

Services listed are not covered unless specifically described as covered in other policies or required by law:

ALL of the following

Investigational or Experimental: Services, items or procedures that are cosmetic: change/improve appearance without significantly improving physiological function
See Cosmetic definitions and lists for examples; routine services associated with investigational cancer treatment may be covered by state regulation.
Drugs/Devices Investigational: Drugs or devices that lack FDA approval
Investigational or experimental services are excluded
Clinical Trials Exclusion: Requested treatment that is part of Phase I or II trials or investigational arm of Phase III trials

Coding

Plan-specific non-covered CPT/HCPCS/ICD-10/Modifier lists (external)mixedNot Covered

External grid

Document references external Non-Covered grids at https://www.nhpri.org/providers/policies-and-guidelines/billing-guidelines-and-payment-policies/ for plan-specific CPT/HCPCS/ICD-10 and modifier listings. Specific codes were added/removed on multiple dates per history.

Provider Actions & Billing Impact

Prior Authorization

Prior authorization recommended for certain infertility drugs

Prior authorization is recommended for drugs for anonymous or designated egg donors that are directly related to a stimulated Assisted Reproductive Technology (ART) cycle, unless the member is the sole recipient of the donor's eggs. Prior approval is required for services rendered by non-network providers unless it is an emergency.

Documentation Required

Documentation required for stolen or destroyed DME items

To replace DME items that were stolen or destroyed, providers must submit required documentation.

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

Background

Purpose and scope: This payment policy documents Neighborhood Health Plan of Rhode Island's coverage exclusions and identifies services, items, and circumstances considered non-covered. It provides examples and categories (e.g., cosmetic procedures, investigational services, DME exclusions, infertility and reproductive exclusions, dental/vision, alternative therapies, transplant-related and other specific exclusions) but should not be interpreted as an all-inclusive list.

Lists are illustrative, not exhaustive: For plan-specific CPT/HCPCS/ICD-10 and modifier exclusions, providers must follow the external Non-Covered grids referenced in the policy; those external code lists are not all-inclusive and are updated periodically.

Claims and limits: Claim payments remain subject to member benefits, eligibility, coding edits, authorizations, provider contract agreements, and applicable state and federal laws; this policy is informational and not a guarantee of reimbursement. Neighborhood may update the policy at any time and reserves rights to audit claims and apply exceptions as required by law.

Operational notes: Prior authorization is recommended or required in certain circumstances (for example, some donor-related infertility drugs and services, and non-network provider services), and documentation requirements apply for items such as replacement of stolen or destroyed DME.

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: performed to reshape normal structures of the body to improve 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.

Revision History

02/14/25revisedLatest

Policy updated; additional codes added/removed from CPT/HCPC and diagnosis lists. Annual/code maintenance updates including cosmetic and infertility language changes noted. (Material)

12/11/24revised

Annual policy review; cosmetic surgery language updated for all lines of business; infertility language updated for Medicaid; speech therapy for voice dysphoria added. (Material)

09/18/24

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-Covered Services Payment Policy – Archive 17

Policy CodePolicy N/A

Change TypeRevised (material and administrative updates)

Effective DateFeb 28, 2017

Next Review Date

Key ActionFollow the plan-specific external Non-Covered CPT/HCPCS/ICD-10/Modifier grids linked in the policy and obtain prior authorization where recommended or required.

SourceLink

On This Page

Services connected to non-covered items: Services delivered in connection with or required by a non-covered item or service

Geographic/Network Restriction: Services provided outside the United States and its territories are excluded

Services must be rendered by network providers unless emergency or prior approval obtained

Billing Rule

Use external non-covered code grid

Follow the plan‑specific external Non‑Covered grids for CPT/HCPCS codes, ICD‑10 diagnoses, and modifiers at the link provided in the policy. Claims billed using codes listed on external non‑covered grids remain subject to claims edits, audits, and payment rules.

Denial Risk

Claims subject to denial if non-covered

Services and items identified as non‑covered (for example cosmetic, investigational, excluded DME, infertility services as described) will not be paid. Such claims remain subject to denial, claims edits, and audit based on member benefits, eligibility, coding rules, authorizations, provider contracts, and federal/state regulations.

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

Policy updated with additional codes added/removed from CPT/HCPC lists and Medicaid surrogate language additions (ongoing coding grid updates).

07/01/24revised

Policy updated with additional codes added/removed from CPT/HCPC lists (ongoing coding grid updates).

03/11/24revised

Annual policy review; additional codes added/removed from CPT/HCPC list and surrogate language added to Medicaid (ongoing coding grid updates).

11/28/23revised

Policy updated with additional codes added/removed from CPT/HCPC list (ongoing coding grid updates).

03/29/23added

Added Concierge Services to Additional Coverage Exclusions, converted CPT/HCPC/ICD-10 and Modifiers lists to external grid, and added GC modifier to Commercial (administrative coding and exclusion list centralization).