Non-covered / Excluded Services and Items

Coverage Summary

This policy covers Neighborhood Health Plan of Rhode Island's exclusions and lists services, supplies, devices, procedures and specific non-covered codes across product lines. It applies to Medicaid (excluding EFP), INTEGRITY, and Commercial product lines and is effective 2017-02-28 with last review on 2023-01-01. The policy includes high-level exclusions and detailed non-covered CPT/HCPCS/ICD-10 codes and modifiers for each plan and notes that exclusions and non-covered code lists are provided in plan‑specific sections.

Key stats

Product lines in scopeMedicaid (excl. EFP), INTEGRITY, Commercial

Document history date range2017-02-28 to 2023-01-01 (multiple updates listed: 01/01/23, 07/18/22, 05/16/22, etc.)

Approx. non-covered codes count>500 codes listed across CPT/HCPCS/ICD-10/modifiers (detailed plan-specific lists)

Medical-Necessity Criteria & Exclusions

General Exclusions / Investigational or Experimental Services

Services are not covered when any of the following apply:

ANY of the following

Drug or device that lacks FDA approval.
Requested treatment that is the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials.
Services which are 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

Durable medical equipment items and services not covered include:

ANY of the following

Purchase, repair, or replacement of materials or equipment resulting from member abuse.
Purchase, repair, or replacement of materials or equipment that has been stolen or destroyed except when documentation provided: Explanation of continuing medical necessity; Explanation that item was stolen/destroyed; Copy of police/fire/insurance report if applicable.
Repair of Neighborhood non-covered DME items.
Repair of DME items covered under the provider's or manufacturer's warranty.
Repair of a rented DME item.

Cosmetic Services Exclusions

Cosmetic procedures and supplies are not covered except as described in covered services. Examples include but are not limited to:

ANY of the following

Cervicoplasty
Chemical exfoliations, peels, abrasions, dermabrasions or planing for acne, scarring, wrinkling, sun damage or other conditions
Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, congenital breast asymmetry
Cosmetic prosthetic devices
Drugs, biological products, hospital charges, pathology, radiology, surgeon/assistant surgeon/attending physician and incidental services related to cosmetic surgery

Dental Exclusions

Dental services not covered:

ANY of the following

Orthodontia.
All dental services other than emergency dental and limited oral surgery.
Adult preventive and restorative services, including routine exams, X-rays, cleanings, tooth extractions, fillings, implants.

Home Modifications / Items for Home Use

Home structural modifications and non-covered home items include:

ANY of the following

Decks
Permanent lifts affixed to the home (not bed-to-chair lifts which are conditionally covered)
Enlarged doorways
Environmental accessibility modifications (grab bars, ramps)
Fences
Handrails

Infertility Exclusions

Infertility-related services and items that are excluded include:

ANY of the following

Home ovulation prediction kits
Infertility treatment for members who do not meet the definition of infertility.
Experimental infertility procedures.
Services for couples where one partner previously had sterilization, with or without reversal.
Costs of surrogacy or gestational carrier arrangements, including drugs for implantation, embryo transfer, cryopreservation, maternity care if surrogate not member, donor recruitment/compensation.

Alternative / Complementary Therapies Exclusions

Alternative therapies not covered include:

ANY of the following

Animal therapy of any type
Dance therapy
Massage therapy
Psychodrama
Yoga
Transcendental meditation

Other General Exclusions

Examples of other non-covered services/items include (not all-inclusive):

ANY of the following

Academic performance testing
Adult respite care (exception: hospice)
Air conditioners, air cleansers, purifiers or HEPA filters
Altered Auditory Feedback Devices
Chronic Care Management Services
Dehumidifiers

Custodial Care Exclusion

Not covered:

Custodial care, rest care, day care, or non-skilled care in any facility including convalescent homes, nursing homes, homes for the aged, halfway houses, or other residential facilities.

Circumcision Setting Restriction

Circumcisions are not covered when performed in the following settings:

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

Network / Setting Restrictions

Coverage condition:

ALL of the following

Services must be rendered by network providers unless emergency or prior approval received.
Services provided in nonconventional settings (e.g., spas/resorts, educational/vocational/recreational settings, wilderness/outward bound programs) are excluded even if provided by licensed providers.
Examples of services that may be excluded in nonconventional settings: Psychotherapy, ABA services, Nutritional counseling.

Pediatric Vision Exclusions

Pediatric vision care exclusions include:

ANY of the following

Services and materials not meeting accepted optometric standards.
Special lens designs or coatings other than those described as covered.
Replacement of lost or stolen eyewear.
Non-prescription (Plano) lenses.
Two pairs of eyeglasses in lieu of bifocals.

Sexual Reassignment / Gender Dysphoria Exclusions

Excluded items include:

ANY of the following

Cryopreservation, storage and thawing of reproductive tissue.
Procedures to enhance masculinity/femininity or alter body contours for aesthetic reasons (considered cosmetic) except treatment of gynecomastia and gender dysphoria exceptions.
Voice modification surgery.
Reversal of genital surgery.

Non‑Covered Codes and Modifiers

Medicaid Non-Covered ICD-10 Codes (partial list shown)ICD-10Not Covered

N46.01
N46.9
N52.9
N97.0
N97.9
Z00.8
Z01.20
Z01.21
Z02.1
Z02.3

1–10 of 32

1/4

Medicaid Non-Covered CPT Codes (partial list shown)CPTNot Covered

0001U
0002M
0002U
0003M
0003U
0004M
0006M
0007M
0005U
0007U

1–10 of 36

1/4

Medicaid Non-Covered HCPCS Codes (partial list shown)HCPCSNot Covered

A0170
A0380
A2001
A2002
A2003
A2004
A2005
A2006
A2007
A2008

1–10 of 15

1/2

INTEGRITY Non-Covered CPT (partial)CPTNot Covered

0012M
0013M
0018M
0021U
0023U
0035U
0038U
0039U
0041U
0042U

1–10 of 15

1/2

INTEGRITY Non-Covered HCPCS (partial)HCPCSNot Covered

A0380
A0394
A0432
A2001
A2002
A2003

Commercial Non-Covered ICD-10 (partial)ICD-10Not Covered

F64.1
F64.2
F64.8
F64.9
L70.0
L70.9
L73.0
L80
N52.9
Z00.8

1–10 of 12

1/2

Non-Covered Modifiers (examples)ModifierNot Covered

EY
GC
GL
HU
HV
HW
HX
HY
HZ
J1

1–10 of 12

1/2

Non-Covered HCPCS ranges and specific codes (Part 2)HCPCSNot Covered

G9389 to G9396
G9402 to G9434
G9451 to G9460
G9468 to G9471
G9679 to G9684
G9890 to G9999
H2038
K1001 to K1006
K1013
K1016 to K1020

1–10 of 78

1/8

Non-Covered CPT (Integrity list)CPTNot Covered

99173
99421 to 99423
99446 to 99450
99455
99456
99461

Non-Covered HCPCS (Integrity list)HCPCSNot Covered

S9901
S9960
S9961
T1004
T1040
T1505
T2001 to T2005
T2007
T2048
T2050

1–10 of 41

1/5

Non-Covered Diagnosis Codes (Commercial)ICD-10Not Covered

F64.1
F64.2
F64.8
F64.9
L70.0 to L70.9
L73.0
L80
N52.9
Z00.8
Z01.20

1–10 of 26

1/3

Non-Covered CPT and HCPCS (Commercial detailed lists)mixedNot Covered

0012M
0013M
0018M
0021U
0023U
0035U
0038U
0039U
0041U to 0044U
0080U

1–10 of 79

1/8

Non-Covered HCPCS (Commercial additional lists)HCPCSNot Covered

A9594
A9597
A9598
B4105
C1734
C1749
C1761
C1823
C1824
C1831

1–10 of 42

1/5

Non-Covered Modifiers (Commercial lists)ModifierNot Covered

EY
GL
HU
HV
HW
HX
HY
HZ
J1
J2

1–10 of 23

1/3

Provider Actions & Billing Guidance

Prior Authorization

Prior approval required for out-of-network or nonconventional settings

Services must be provided by network providers unless it is an emergency or prior approval has been received. Services, programs, supplies or procedures provided in nonconventional settings (for example spas/resorts, educational/vocational/recreational settings, outward bound/wilderness programs, or services performed outside the United States and its territories) are excluded unless prior approval is obtained.

Documentation Required

Documentation for stolen/destroyed DME required

For replacement of DME items that were stolen or destroyed, submit documentation showing the 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 if applicable.

Explanation of continuing medical necessity

Background & Definitions

This policy enumerates services, supplies, devices and procedures that Neighborhood Health Plan of Rhode Island excludes from coverage and identifies services considered non-covered. It clarifies investigational/service‑setting exclusions, durable medical equipment, cosmetic, dental, infertility, alternative therapies, pediatric vision and many other general exclusions, and it provides plan‑specific lists of non‑covered CPT, HCPCS, ICD‑10 codes and modifiers. This document is Part 2 listing additional non‑covered CPT/HCPCS/ICD‑10 codes and modifiers for Commercial and INTEGRITY lines and references plan pages for Medicaid, INTEGRITY and Commercial non‑covered code lists.

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, a procedure performed to reshape normal structures of the body in order to improve the patient's appearance and self‑esteem.

Additional terms: Where used, investigational/experimental services refer to drugs or devices lacking FDA approval or treatments that are the subject of Phase I/II trials or investigational arms of Phase III trials; Routine services associated with investigational cancer treatments are an exception per state regulation.

Revision History

01/01/23revised

01/01/23 Annual Policy Review Date. Policy Updated: additional codes added/removed from CPT/HCPC list. Document history lists multiple prior updates adding/removing codes and modifiers.

07/18/22revised

07/18/22 Policy Updated: additional codes added/removed from CPT/HCPC list.

05/16/22revised

05/16/22 Policy Updated: additional codes added/removed from CPT/HCPC list. Non-covered modifiers were added to Coding grid.