CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Implant Services

Defines which surgically implanted devices are covered or excluded under Neighborhood Health Plan of Rhode Island benefits, and identifies implants that require medical review/contracting. Applies to multiple benefit packages including Rite Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One, and ACA Adult Expansion; Extended Family Planning has limited contraceptive implant coverage.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyImplant Services

Policy CodePolicy N/A

Change TypeNo material clinical changes documented

Effective DateJul 6, 2010

Next Review Date

Key ActionProviders should follow Neighborhood's medical review and contracting processes and obtain required approvals/prior authorization when submitting claims for implants.

POLICY UPDATE CHANGES

Policy creation date is 07/06/10 and review date 10/3/13; no clinical policy statement changes documented in revision history.

5Example Covered Implant Types Listed

5Explicit Exclusions Listed

6Benefit Packages Mentioned

Coverage Summary

Overview: This policy defines which surgically implanted devices are covered or excluded under Neighborhood Health Plan of Rhode Island benefits and identifies implants that require medical review and contracting. Scope: applies to multiple benefit packages including Rite Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One, and ACA Adult Expansion; Extended Family Planning is a limited benefit package with coverage only for specific contraceptive implants. Coverage stance: mixed. Effective date: 2010-07-06. Last review date: 2013-10-03.

Medically Necessary Criteria

Medically Necessary / Covered Implants

Covered when ALL of the following general program-level conditions are met:

Medically Necessary / Covered Implants - Top Level

FDA approval / evidence: Implant is an FDA-approved device or sufficient evidence exists demonstrating net health outcome improvement for the indicated use
Non-FDA approved implants or implants with insufficient evidence are excluded
Medically indicated use: Implant is used for a medically indicated purpose (not cosmetic, not gender reassignment, except where specific exception noted)
Breast implants covered only for breast reconstruction post mastectomy
Benefit package coverage: Implant is provided within a covered benefit package (e.g., Rite Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, Rhody Health Options Phase One, ACA Adult Expansion)
Extended Family Planning: only specific contraceptive implants are covered
Medical review / contracting: Implant procedures subject to specific medical review and contracting as required by Neighborhood for certain devices
Operational prior authorization/contracting may be required (not otherwise specified in this document)

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Examples of Covered Implant Types

Implements considered covered when meeting general medical necessity and program requirements:

Examples of Covered Implant Types - Top Level

Cochlear implants
Pacemakers
Defibrillators
Neurostimulators
Additional surgical implants: Additional implants utilized during surgery that meet general guidelines for coverage noted above

Not Medically Necessary / Exclusions

The following are NOT covered:

Not Medically Necessary / Exclusions - Top Level

Dental implants
Dental services are not covered
Cosmetic implants: Implants for cosmetic reasons
Cosmetic implants are excluded
Gender reassignment implants: Implants for gender reassignment
Breast implants except reconstruction: Breast implants (except for breast reconstruction post mastectomy)
Breast implants are excluded except for reconstruction post mastectomy
Non-FDA approved implants
Or implants without sufficient evidence of net health outcome improvement

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Provider Actions and Requirements

Documentation Required

Medical review and contracting required for some implants

Certain implants require specific medical review and contracting considerations to ensure effective claims adjudication; providers should follow Neighborhood's medical review/contracting processes when submitting claims for implants.

Prior Authorization

Prior authorization/medical review may be required

Implants that require specific medical review and contracting may need prior authorization; providers must obtain required approvals per Neighborhood's processes before implantation.

Background

Background and rationale: Implants encompass a wide array of surgically implanted devices placed in inpatient or outpatient settings by clinicians ranging from primary care practitioners to specialists. While Neighborhood expects high quality, cost‑effective care, certain implants require more detailed support — including medical review and contracting — to ensure effective claims adjudication and appropriate coverage determinations.

Neighborhood specifies examples of implants that are considered covered when they meet medical necessity and program requirements (for example, cochlear implants, pacemakers, defibrillators, and neurostimulators) and also lists exclusions (for example, dental implants, cosmetic implants, gender reassignment implants, most breast implants except reconstruction post mastectomy, and non‑FDA approved implants or those lacking sufficient evidence). Providers should follow Neighborhood's medical review, contracting, and prior authorization processes where required before implantation.