CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non‑Covered and Excluded Services

Defines services, supplies, devices, and procedures that Neighborhood Health Plan of Rhode Island excludes from coverage across Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon‑Covered and Excluded Services (coverage/exclusions)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit requests for listed non‑covered services for prior authorization; such requests will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>10Cosmetic exclusions

20+ rangesNon-covered CPT codes

20+ pagesCode list pages

Network-onlyNetwork requirement

multipleDME exclusions

Non‑Covered Services and Exclusions

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General Non-Covered Services

Not covered when the service or item is listed below

Primary Exclusion: Services and items explicitly listed in the policy (see Non-DME, DME, Cosmetic, Dental, Home Modifications, Alternative Therapies, Additional Exclusions) are not covered.

Applies to Medicaid (excl. EFP), INTEGRITY, Commercial as stated in Scope

Investigational/Experimental Services

Not covered when ALL of the following are true

Investigational or Experimental Services: Drugs or devices that lack FDA approval; services delivered in connection with or required by a non-covered item or service; requested treatments that are the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials are considered investigational/experimental and not covered.

Exception: investigational/experimental services are covered for cancer treatment per State regulation.

DME Exclusions and Exception Documentation

DME is not covered when any of the following apply

DME Exclusions: Purchase, repair, or replacement resulting from enrollee abuse; repair of items not covered by Neighborhood; repair of DME items covered under the provider's or manufacturer's warranty; repair of a rented DME item are not covered.

If item is stolen or destroyed, coverage may be considered only with documentation: explanation of theft/destruction, explanation of continuing medical necessity, and police/fire/insurance report copy if applicable.

Cosmetic Procedures and Surgery

Cosmetic procedures and surgeries are not covered except as described in covered services

Cosmetic Exclusions: Procedures or services that change or improve appearance without significantly improving physiological function are excluded. Examples include cervicoplasty; augmentation mammoplasty, mastopexy; chemical peels and dermabrasion; excision of excess skin (brachioplasty, abdominoplasty except panniculectomy); genioplasty; hair removal and hair transplants; gynecomastia surgery; laser treatments for acne/scars; liposuction; rhinoplasty; otoplasty; rhytidectomy; scar revision; tattooing/tattoo removal (except nipple/areola post-mastectomy); testicular prosthesis surgery; cosmetic prosthetic devices; and related incidental charges.

Includes exclusion of incidental charges related to cosmetic surgery; medically necessary procedures performed at the same time as a cosmetic procedure are noted separately.

Dental and Infertility Exclusions

Not covered when service matches listed dental or infertility exclusions

Dental Exclusions: Orthodontia and all dental services for adults, other than emergency dental care and limited oral surgery, are not covered (examples: routine exams, X-rays, cleanings, restorative services, extractions, fillings, implants).

Infertility/Assisted Reproduction Exclusions: Experimental infertility procedures; services for members who do not meet the definition of infertility; reversal of voluntary sterilization; costs for drugs needed for implantation, embryo transfer, and cryopreservation; surrogacy costs (including carrier/gestational carrier expenses), donor recruitment/compensation, procurement of frozen donor oocytes; long-term (>90 days) sperm or embryo cryopreservation unless member is in active infertility treatment; donor sperm/lab services when no diagnosed male factor infertility; and other associated non-covered items are excluded.

Short-term (<90 days) cryopreservation of sperm or embryos may be authorized for certain medical conditions; prior authorization is recommended for some infertility-related services.

Home Modifications and Non-DME Items

Not covered when items are for general home modification or household use

Home Modifications: Environmental accessibility modifications that are permanent or structural (decks, permanent lifts affixed to the home, enlarged doorways, grab bars/ramps, fences, handrails, room additions/expansions, telephone alert systems, telephone service in the home) are excluded. (Bed-to-chair lifts may be conditionally covered; permanent home lifts are excluded.)

Non-DME Household Items: Household items such as air conditioners (window or central), air purifiers/HEPA filters, dehumidifiers, floor mats, trampolines/mini trampolines, suspension swings, hypoallergenic pillows/bedding, standard car seats, waterproof casts, and specialty diet food products are not covered.

Alternative Therapies

Not covered when service is an alternative therapy listed

Alternative Therapy Exclusions: Animal-assisted therapy of any type, massage therapy, dance therapy, psychodrama, yoga, transcendental meditation, hypnotherapy, and similar alternative medicine services are excluded.

Biofeedback is not covered except when used to treat urinary incontinence per the document.

Additional Coverage Exclusions

Not covered when service is listed under Additional Coverage Exclusions

Additional Exclusions: Examples of additional non-covered items include altered auditory feedback devices; academic or educational testing; chronic care management services; diagnostic tests to evaluate need for a non-covered service; drugs/devices for sexual or erectile dysfunction; Lasik surgery; health club memberships; medical marijuana; personal emergency response systems; planned home births; private hospital rooms unless medically necessary; sperm banking; services provided outside the United States; vocational rehabilitation; and wigs (except for alopecia and cancer treatment).

Some exceptions are noted in the document (e.g., wigs for alopecia/cancer).

Not Covered / Exclusions

Services and items explicitly excluded from coverage include, but are not limited to, the following categories:

General Exclusions: Abortion services (except to preserve life or in cases of rape or incest); altered auditory feedback devices; academic performance testing; cord blood banking; critical care transport; diagnostic tests to evaluate need for a non-covered service; drugs/devices for sexual or erectile dysfunction; electro-sleep therapy; educational testing/training programs; Lasik; IV histamine therapy; medical marijuana; planned home births; private rooms (unless medically necessary); sperm banking; thermogenic therapy; vocational rehabilitation; wigs (except alopecia and cancer treatment).

Alternative/Complementary Medicine: Alternative medicine services such as hypnotherapy and biofeedback (biofeedback not covered except for urinary incontinence) are excluded.

Circumcision Setting Restriction: Circumcisions performed outside of a hospital or physician's office are not covered.

Cosmetic Procedures:

The policy explicitly excludes a broad set of cosmetic procedures and surgeries that are intended to change or improve appearance without significant physiological benefit. Examples called out in the document include, but are not limited to: cervicoplasty, augmentation mammoplasty, mastopexy, correction of congenital breast asymmetry, chemical exfoliations/peels/dermabrasion, cosmetic prosthetic devices, excision of excess skin (brachioplasty, abdominoplasty except panniculectomy), genioplasty, hair removal (including electrolysis), gynecomastia surgery, hair transplants, inverted nipple surgery, laser treatment for acne/scars, liposuction/suction-assisted lipectomy, osteoplasty, otoplasty, rhinoplasty, rhytidectomy (facelift), scar revision, subcutaneous filler injections, sclerotherapy for spider veins, tattooing/tattoo removal (except nipple/areola post-mastectomy), treatment of vitiligo, testicular prosthesis surgery. Incidental charges related to cosmetic surgery (e.g., hospital, pathology, radiology, surgeon/assistant fees) are also excluded except where services meet covered-service exceptions.

Durable medical equipment (DME) is excluded when purchase, repair, or replacement is the result of enrollee abuse, when the item is destroyed unless adequate documentation is provided, for repair of rented DME items, and for repair of items covered under the provider's or manufacturer's warranty. When an item is stolen or destroyed, coverage may be considered only with documentation such as an explanation of theft/destruction, an explanation of continuing medical necessity, and a copy of a police/fire/insurance report if applicable.

Services and items that are investigational or experimental are not covered. This includes drugs or devices that lack FDA approval, services delivered in connection with or required by a non-covered item or service, and treatments that are the subject of Phase I/II clinical trials or investigational arms of Phase III trials. Exception: investigational or experimental services are covered for cancer treatment per State regulation.

The policy lists numerous additional non-covered services and categories. Representative exclusions include: abortion services (except to preserve life or in legally specified circumstances), cord blood banking, drugs/devices for sexual or erectile dysfunction, LASIK, medical marijuana, private hospital rooms (unless medically necessary), sperm banking, vocational rehabilitation, wigs (except for alopecia and cancer treatment), custodial/non‑skilled care, adult preventive and restorative dental services, certain devices and appliances (e.g., dehumidifiers, deluxe eyeglass frames, refractive eye surgery for correctable conditions), experimental/new treatments (with limited legal exceptions), many infertility-related services (including long-term cryopreservation, surrogacy costs), and network/nonconventional setting restrictions. The list in the document is extensive and not exhaustive here; providers should consult the full exclusions for specific items.

Items and services related to sexual reassignment and gender dysphoria treatment are specifically excluded in multiple respects. Examples listed include cryopreservation, storage and thawing of reproductive tissue, and voice modification surgery. The policy also states that procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are considered cosmetic and excluded unless performed for the treatment of gynecomastia or gender dysphoria as noted.

Transportation services are excluded where they are provided by non-covered transport modalities. Specifically, reimbursement is not provided for transportation by chair car, wheelchair van, or taxi except as otherwise required by coverage rules or law.

The policy enumerates other administrative and service-level exclusions. Examples include charges for copying or forwarding member records (charts or X‑rays), provider charges for missed appointments, chronic care management service fees, examinations or services intended for educational or vocational purposes, electrolysis, exercise classes, personal trainer fees, personal emergency response systems, TENS units and related supplies, waterproof casts, and medical marijuana.

The document contains extensive, line-of-business-specific code lists of non-covered items. For Medicaid, INTEGRITY, and Commercial lines the policy enumerates numerous ICD-10 diagnosis and ICD-10-PCS procedure codes, CPT codes, and HCPCS codes that are designated non-covered. These lists are provided in the Non-Covered Services sections for each line of business and must be consulted directly for the precise code-level exclusions.

The INTEGRITY section explicitly lists a set of CPT, HCPCS, and ICD-10-PCS codes that are excluded from coverage. The policy identifies specific CPT examples (e.g., 3294F, 3323F, 3324F, 3328F, 32994, 33274, 33275, 33289) and multiple HCPCS and ICD‑10‑PCS ranges; claims using these codes may be denied as non-covered.

The Commercial section likewise enumerates CPT, HCPCS, ICD‑10‑PCS, and diagnosis codes that are excluded. Representative CPT entries shown include 20985, 22505, 22586, ranges 22867–22870, 3293F, 3294F, 3323F, 3324F, 3328F and many molecular/pathology and procedure codes; HCPCS examples and diagnosis codes are also listed. Providers must reference the Commercial non‑covered code lists when submitting claims to avoid denials.

The policy clarifies that services which primarily change or improve appearance without a significant physiological benefit are considered not medically necessary and therefore not covered. This includes cosmetic procedures and cosmetic surgery as defined in the document (procedures to reshape normal body structures to improve appearance and self‑esteem).

More specifically, procedures performed solely to improve appearance without a meaningful physiological improvement are identified as not medically necessary. Examples highlighted include common cosmetic services such as rhinoplasty, facelifts, liposuction, scar revisions, and similar procedures performed for aesthetic purposes.

The policy lists classes of procedures considered cosmetic when their primary purpose is aesthetic, including procedures that alter body contours to enhance perceived masculinity or femininity. Such procedures are excluded unless a specific medical exception applies (for example, treatment of gynecomastia or clinically indicated gender dysphoria interventions as noted).

Non‑Covered Codes by Payer Line

Non-covered ICD-10-PCS Codes: Medicaid / ConsolidatedICD-10Not Covered

O8POOJZ	specified ICD-10-PCS procedure
O8P03JZ	specified ICD-10-PCS procedure
O8WOOJZ	specified ICD-10-PCS procedure
O8WO3JZ	specified ICD-10-PCS procedure
O8W1OJZ	specified ICD-10-PCS procedure
O8W13JZ	specified ICD-10-PCS procedure
OC9WOOO	specified range start (OC9WOOO-OC9XXZ2)
OC9XXZ2	specified range end (OC9WOOO-OC9XXZ2)
OCSWOZO	range examples in series (OCSWOZO-OCSXXZ2)
OCSXXZ2	range end

1–10 of 16
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Non-covered CPT Codes: Medicaid / ConsolidatedCPTNot Covered

0010M	specific CPT code - molecular/pathology / genetic testing series
0012M	specific CPT code
0013M	specific CPT code
0018M	specific CPT code
0035U	proprietary lab test series start (0035U-0039U)
0039U	proprietary lab test series end
0041U	proprietary lab test
0044U	proprietary lab test end
0081U	proprietary lab test
0141T	Category III / temporary code

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1/4

Non-covered HCPCS Codes: Medicaid / ConsolidatedHCPCSNot Covered

A0380	respiratory/ventilation related device
A0394	transport / specimen service
A0432	non-emergency ambulance
A4336	device supply code
A4337	device supply code
A4360	device supply code
A4459	medical supply
A4466	medical supply
A4467	medical supply
A4490	medical supply

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What Providers Must Do / Watch For

Prior Authorization
Prior authorization not applicable for listed non‑covered services
Requests for services that are listed as non‑covered in this policy should not be submitted for prior authorization. Submitting authorization for items explicitly designated as non‑covered may result in denial.
Do not submit prior authorization requests for services listed as non‑covered in the INTEGRITY or Commercial code lists.
Prior approval is required for services rendered out‑of‑network except in emergencies — obtain prior approval where applicable.

Note
Check plan‑specific code lists
Review the plan‑specific non‑covered code listings before billing or requesting authorization. The policy includes separate non‑covered code lists for Medicaid, INTEGRITY, and Commercial lines — these lists are not exhaustive; confirm applicability to the member and plan.
Medicaid Non‑Covered Codes: see plan list (referenced pages in policy).
INTEGRITY Non‑Covered Codes: see plan list.
Commercial Non‑Covered Codes: see plan list.

Billing Rule
INTEGRITY non‑covered code examples
The INTEGRITY section of this policy identifies CPT and HCPCS codes that are considered non‑covered. Providers should not bill these codes when seeking reimbursement or submit them for prior authorization.
Example INTEGRITY non‑covered CPT/HCPCS codes include: 3294F, 3323F, 3324F, 3328F, 32994, 33274, 33275, 33289, 33927–33929, 34839, 34841–34848, 36416, 3650F, 3700F, 3720F, G0157, G0158, G0162, G0219, G0235, G0252, G0294, G0295, G0380–G0384.

Billing Rule
Commercial non‑covered code examples
The Commercial section of this policy identifies CPT and HCPCS codes that are considered non‑covered. Providers must avoid billing these codes when seeking reimbursement or submitting prior authorization requests.
Example Commercial non‑covered CPT/HCPCS codes include: 20985, 22505, 22586, 22867–22870, 3293F, 3294F, 3323F, 3324F, 3328F, 32994, 33274, 33275, 33289, 33340, 33927–33929, 34839, 34841–34848, 36416, 3650F, 3700F, 3720F, HCPCS E0172, E0175, E0190, E0231, E0232, E0240–E0249.

Documentation Required
DME loss and repair documentation
When a DME item is stolen or destroyed, providers must submit supporting documentation to avoid denial. Claims for DME lost due to enrollee abuse may be denied.
Provide an explanation that the item was stolen or destroyed.
Provide documentation of continuing medical necessity for the item.
Include police, fire department, or insurance reports if applicable (copies).
Claims for DME resulting from enrollee abuse or without required documentation may be denied.

Denial Risk
Providers must avoid billing listed non‑covered codes
Providers must not bill CPT, HCPCS, or other listed codes identified as non‑covered in the plan‑specific lists when seeking reimbursement. Submitting claims or authorization requests using these non‑covered codes can trigger denials and audits.
Avoid billing codes listed on the INTEGRITY and Commercial non‑covered code lists.
Claims are subject to eligibility, coverage edits, documentation guidelines, authorization policies, and may be audited.
Services listed under exclusions (e.g., cryopreservation, voice modification, cosmetic procedures) may be denied if billed as covered.

Policy Background and Scope

This section enumerates services and items considered cosmetic, custodial, experimental, or otherwise non-covered by the plan. It clarifies that the exclusions are broad, that some narrow medically necessary exceptions may exist, and that providers should consult the policy and the line-of-business code lists for precise applicability and potential legal exceptions (for example, investigational cancer therapies covered per State regulation).

Key Definitions

Cosmetic Procedure / Cosmetic Surgery — Definition and examples

DefinitionProcedures or services that change or improve appearance without significantly improving physiological function (Cosmetic Procedure/Cosmetic Surgery).

Source definitionCosmetic Surgery defined per American Society of Plastic Surgeons: performed to reshape normal structures of the body to improve appearance and self-esteem.

Examples (non-exhaustive)Includes cervicoplasty, augmentation mammoplasty, mastopexy, chemical peels/dermabrasion, cosmetic prosthetic devices, brachioplasty, abdominoplasty (except panniculectomy), genioplasty, hair removal/transplants, inverted nipple surgery, laser acne treatments, liposuction, osteoplasty, otoplasty, rhinoplasty, rhytidectomy, scar revision, tattooing/tattoo removal (except post-mastectomy areola), sclerotherapy, testicular prosthesis surgery.

Cosmetic Surgery / Procedure — Definition and examples

DefinitionProcedures or services performed primarily to change or improve appearance without significant physiological benefit (Cosmetic Surgery/Procedure).

Illustrative excluded proceduresGynecomastia surgery, hair transplants/removal, otoplasty, rhinoplasty, liposuction, scar revision, rhytidectomy (facelift), subcutaneous filler injections, tattooing/tattoo removal (with exceptions), treatment of vitiligo, sclerotherapy for spider veins.

Related charges excludedBiological products, hospital/surgeon/assistant/pathology/radiology fees and any incidental services related to cosmetic surgery are excluded unless described in covered services.

Surrogate / Gestational Carrier — Definition

DefinitionSurrogate: 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.

Coverage implicationSurrogacy-related services and costs (see infertility exclusions) are listed as non-covered in the policy, including donor/surrogacy costs and related procurement/compensation.

Sexual reassignment/gender dysphoria treatment exclusions — enumerated excluded items

Cryopreservation and storageCryopreservation, storage and thawing of reproductive tissue are excluded from coverage.

Voice modification surgeryVoice modification surgery is excluded from coverage.

Cosmetic body-contouring proceduresProcedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are considered cosmetic and are excluded unless for treatment of gynecomastia and gender dysphoria.

Reversal of genital surgeryReversal of genital surgery is excluded from coverage.

Policy Revision History

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon‑Covered and Excluded Services (coverage/exclusions)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit requests for listed non‑covered services for prior authorization; such requests will be denied.

SourceLink

On This Page

A broad range of cosmetic procedures and surgeries (e.g., cervicoplasty, augmentation mammoplasty, facelifts, liposuction, rhinoplasty, scar revision, hair transplants/removal, otoplasty, rhytidectomy, tattooing/tattoo removal except nipple/areola post-mastectomy) are excluded.

Custodial Care: Custodial, rest, or non-skilled care in residential facilities (convalescent homes, nursing homes, homes for the aged, halfway houses) is not covered.

Adult Dental Care: Adult preventive and restorative dental services, including routine exams, X-rays, cleanings, restorative treatments (extractions, fillings, implants), are not covered.

Devices, Appliances, Prosthetics Exclusions: Non-covered devices include dehumidifiers, orthotic appliances intended to straighten or reshape a body part (e.g., foot orthotics, cranial banding), devices to reduce snoring (laser-assisted uvulopalatoplasty, somnoplasty, snore guards), some braces (including OTC orthotic braces), deluxe frames, and refractive eye surgery for correctable conditions.

Experimental or New Services: Experimental or investigational treatments are not covered except where Rhode Island or federal law provides coverage (e.g., certain cancer therapies); costs associated with doula services are not covered.

Human Organ Transplants: Experimental transplant procedures (except as required by law), donor search expenses, donor services not directly related to transplant, and cord blood collection/preservation for potential future use are excluded.

Infertility Services: Experimental infertility procedures; services for members who do not meet the definition of infertility; reversal of voluntary sterilization; long-term cryopreservation (>90 days) unless in active infertility treatment; donor recruitment/compensation; donor sperm and related lab services without diagnosed male factor infertility; procurement of frozen donor oocytes; surrogacy costs and related expenses are not covered.

Prior authorization is recommended for certain infertility-related services; short-term cryopreservation may be authorized in narrow circumstances.

Network Restrictions and Nonconventional Settings: Services must be provided by network providers unless emergency or prior approval is received; services provided in nonconventional settings (educational/vocational/recreational settings, spas/resorts, wilderness camps, services performed outside the U.S.) are excluded even if provided by licensed professionals.

Over-the-counter Contraceptives: Over-the-counter contraceptive agents are not covered.

Gender Dysphoria / Sexual Reassignment Exclusions: Cryopreservation, storage and thawing of reproductive tissue; voice modification surgery; procedures to alter body contours for aesthetic reasons (considered cosmetic) and reversal of genital surgery are excluded; exceptions for gynecomastia and gender dysphoria treatment are noted elsewhere.

Transportation by chair car, wheelchair van, or taxi is not covered.