Neighborhood Health Plan non-covered services Policy Update

Non-Covered Services and Exclusions

Not Covered / Exclusions

The following services and items are explicitly not covered by the plan unless otherwise stated:

Cosmetic Procedures

Examples: Includes cervicoplasty; correction of variations in normal anatomy (augmentation mammoplasty, mastopexy, correction of congenital breast asymmetry); chemical exfoliations/peels/dermabrasion; genioplasty; excision of excess skin or subcutaneous tissue (e.g., brachioplasty, abdominoplasty) except panniculectomy; gynecomastia surgery; hair transplants and hair removal (including electrolysis/epilation); inverted nipple surgery; laser treatment for acne and acne scars; liposuction/suction-assisted lipectomy; osteoplasty; otoplasty; rhinoplasty; rhytidectomy (facelift); scar revision (regardless of symptoms); subcutaneous injection of filler materials; sclerotherapy for spider veins; tattooing or tattoo removal (except nipple/areola related to mastectomy); treatment of vitiligo; testicular prosthesis surgery; scalp hair prostheses/wigs for hair loss due to alopecia areata/totalis or permanent loss due to injury; removal/destruction of skin tags; repeated cauterizations or electrofulguration to remove skin growths.
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Circumcision Setting: Circumcisions are not covered if performed in any setting other than a hospital, day surgery, or a physician's office.

Chunk 18

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

Chunk 22

Dental Services: Adult preventive and restorative dental services, treatments, and supplies (e.g., routine exams, X-rays, cleanings, restorative procedures such as fillings, extractions, implants) are not covered except where specifically stated as covered (emergency dental and limited oral surgery exceptions noted in policy).

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Eyeglasses/Refractive Surgery and Vision Items: Deluxe frames, refractive eye surgery (including radial keratotomy) for conditions correctable by non-surgical means, replacement of lost or stolen eyewear, non-prescription lenses, and other non-covered vision materials are not covered.

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Experimental/Investigational Transplants: Experimental or investigational transplant procedures are not covered; transplants of the face and hand are considered experimental and therefore not covered except as required by law.

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Infertility Services: Infertility treatment and related costs are not covered for many services including experimental infertility procedures, members not meeting the policy definition of infertility, reversal of voluntary sterilization, surrogacy costs (including drugs, implantation, embryo transfer, cryopreservation >90 days except limited short-term exceptions), donor egg/sperm costs in many circumstances, and related laboratory and maternity costs when the surrogate is not a member. Prior authorization is recommended for ART-related services.

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Network and Setting Restrictions: Services must be rendered by network providers unless emergency or prior approval; services, programs, supplies or procedures provided in nonconventional settings (educational/vocational/recreational settings, spas/resorts, wilderness camps, services performed outside the U.S.) may be excluded even if provided by licensed practitioners.

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Over-the-counter and Pediatric Vision Exceptions: Over-the-counter contraceptive agents are not covered; certain pediatric vision services and materials not meeting covered service standards (special lens designs/coatings, replacement of lost/stolen eyewear, non-prescription lenses) are excluded.

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Sex Reassignment / Gender Dysphoria Related Exclusions: Procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are considered cosmetic and excluded unless for treatment of gynecomastia or gender dysphoria; cryopreservation/storage/thawing of reproductive tissue and voice modification surgery are excluded.

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Miscellaneous Additional Exclusions: A broad list of additional non-covered items and services including, but not limited to: care covered under other federal/state/local programs (e.g., workers' compensation), provider charges for missed appointments, charges for copies of member records, chronic care management services, electrolysis, concierge service fees or retainers, examinations/evaluations for educational or vocational purposes, exercise classes, homemaker services, medical marijuana, personal emergency response systems, planned home births, relaxation and massage therapies, services/supplies required by a third party that are not medically necessary, TENS units and related supplies, vitrectomy chairs, waterproof casts, weighted vests/blankets, weight loss programs and clinics (inpatient and outpatient), and other items listed in the policy.

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This policy designates Investigational or Experimental services as items, devices, or treatments that lack FDA approval or that are the subject of early‑phase clinical research. Examples include devices or drugs without FDA approval and treatments that are the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III clinical trials. Services delivered in connection with, or required by, a non‑covered investigational item are also considered investigational. Routine services associated with investigational cancer treatments are an exception and are covered per state regulation.

Durable medical equipment (DME) is excluded in several specific situations: the purchase, repair, or replacement of DME resulting from member abuse is not covered; repairs of DME that are covered under the provider’s or manufacturer’s warranty or repairs of rented DME are not covered. Replacement of items that have been stolen or destroyed is not covered unless documentation is provided (explanation that the item was stolen or destroyed, explanation of continuing medical necessity, and police/fire/insurance report copy if applicable). Claims for DME are subject to applicable documentation requirements to support coverage.

Circumcision procedures are excluded when performed outside accepted clinical settings. Specifically, circumcisions will not be covered if they are performed in any setting other than a hospital, day surgery, or a physician’s office. Providers should ensure the procedure setting meets these requirements to avoid denial.

Cosmetic services are not covered when the primary purpose is to change or improve appearance without significantly improving physiological function. The policy defines Cosmetic Procedure as procedures or services that change or improve appearance without significant physiologic benefit, and references the American Society of Plastic Surgeons definition of cosmetic surgery. Examples of non‑covered cosmetic procedures include, but are not limited to: cervicoplasty; augmentation mammoplasty and mastopexy; chemical peels and dermabrasion; cosmetic prosthetic devices; excision of excess skin (e.g., brachioplasty, abdominoplasty except panniculectomy); genioplasty; hair removal and hair transplants; gynecomastia surgery; inverted nipple surgery; laser treatments for acne/scarring; liposuction; osteoplasty; otoplasty; rhinoplasty; rhytidectomy (facelift); scar revision; subcutaneous injectable fillers; sclerotherapy; tattooing or tattoo removal (except nipple/areola related to mastectomy); testicular prosthesis surgery; and scalp hair prostheses/wigs (subject to listed exceptions).

Most dental services are excluded. Orthodontia and all dental services other than emergency dental care and limited oral surgery are not covered (examples include routine exams, X‑rays, cleanings, restorative services). Infertility services and related costs are broadly excluded in many circumstances — experimental infertility procedures, costs for implantation/embryo transfer and cryopreservation, surrogacy costs, donor recruitment/compensation, donor sperm in the absence of male factor infertility, and long‑term cryopreservation (greater than 90 days) are listed as non‑covered. Note: prior authorization is recommended for assisted reproductive technology (ART)‑related services where benefits apply.

Alternative and complementary therapies are excluded. Examples of non‑covered alternative therapies include animal‑assisted therapy, massage therapy, dance therapy, psychodrama, yoga, transcendental meditation, and similar modalities. Biofeedback is excluded except where specifically indicated (e.g., urinary incontinence per policy exceptions).

A broad set of miscellaneous items and services are explicitly excluded. Non‑covered examples include adult respite care (except hospice), academic testing, air conditioners/dehumidifiers/air purifiers, concierge service fees or retainers, health club memberships, LASIK/refractive surgery, medical marijuana, personal emergency response systems, planned home births, sperm banking (subject to limited exceptions), wigs (except for alopecia and cancer treatment), TENS units and related supplies, weight‑loss programs and clinics (inpatient and outpatient), and many other durable medical equipment, home modification and administrative items. Claims for these items are subject to denial as non‑covered.

The policy reiterates that any service, supply, or medication intended to change or improve appearance is not covered except where specifically described as a covered service. Additional cosmetic examples called out across the document include scar revision (not covered regardless of symptoms), injectable fillers, sclerotherapy, tattooing/tattoo removal (except nipple/areola in post‑mastectomy reconstruction), and vitiligo treatment.

Transplant procedures that are experimental or investigational are excluded. Specifically, face and hand transplants are considered experimental and are not covered (except when required by federal or state law). Related transplant‑associated services and donor expenses not directly related to the covered transplant recipient are also excluded.

General exclusions also encompass services covered under other programs and administrative or non‑medical charges. Examples include care covered by federal, state or local programs (such as workers’ compensation and no‑fault automobile insurance), provider charges for missed appointments, charges for copies of member records, chronic care management services, electrolysis, concierge fees, examinations for educational or vocational purposes, exercise classes, homemaker services, office infection control charges, planned home births, and services provided to non‑members except as described under covered services.

Scar revision is explicitly listed as not medically necessary and not covered. The policy states that scar revision is not covered regardless of symptoms, and scar revision is included among the cosmetic procedures treated as not medically necessary because the primary purpose is appearance alteration rather than physiologic benefit.

Scar revision is denied as a non‑covered service. Scar revision — regardless of symptoms — is excluded from coverage.

Procedures performed to enhance gender characteristics or to alter body contours purely for aesthetic reasons are considered cosmetic and excluded. The policy specifies that procedures designed to enhance masculinity or femininity or to alter body contours for aesthetic reasons are considered cosmetic and excluded, with the exception of services needed for treatment of gynecomastia and those medically necessary for gender dysphoria as referenced elsewhere.

Coding Lists and References

Non-covered coding lists (external)mixed

See external grids

Non-covered CPT, HCPCS, ICD-10 diagnosis codes and Modifiers are listed in separate non-covered specific listings grids (link referenced).

Non-Covered / Coding Lists (external)mixed

see external grid

Plan-specific lists of non-covered CPT, HCPCS, ICD-10 Diagnosis codes, and Modifiers are maintained on an external link referenced by the policy.

Provider Requirements, Authorization, and Documentation

Billing Rule

Coding and Authorization References

Services billed to Neighborhood are subject to coverage determination, member eligibility, claim-edit rules, required documentation, and prior authorization requirements. Providers must follow plan coding and authorization processes and use the separate non-covered code grids when submitting claims.

Refer to the plan's Non‑Covered Code Grids for CPT, HCPCS, ICD‑10, and Modifiers before billing
Verify member eligibility and benefits prior to rendering services
Submit prior authorization requests when required by the plan's authorization policies
Maintain and furnish clinical documentation upon request to support medical necessity, coding, and payment

Documentation Required

Policy Background and Scope

Background: This policy identifies categories of services that Neighborhood Health Plan of Rhode Island does not cover, intended to guide billing, preauthorization, and claims adjudication. Excluded categories include investigational/experimental services, cosmetic procedures, certain DME replacement and repair scenarios, most dental services, alternative therapies, infertility‑related services in many circumstances, experimental transplants (including face and hand), and a wide set of miscellaneous administrative, durable equipment, and non‑medical items. The policy applies to the plan’s applicable lines of business and should be used to inform prior authorization and documentation requirements.

Key Definitions

Cosmetic Procedure / Cosmetic Surgery

DefinitionProcedures or services that change or improve appearance without significantly improving physiological function.

Cosmetic Surgery (per ASPS)Surgery performed to reshape normal structures of the body in order to improve the patient’s appearance and self‑esteem (American Society of Plastic Surgeons definition).

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

Investigational or Experimental Services

DefinitionServices or devices that lack FDA approval, or treatments that are the subject of Phase I or Phase II clinical trials or the investigational arm of Phase III trials.

Related services

OpenPayer

Non-covered and cosmetic services exclusions

Non-Covered Services and Exclusions

Coding Lists and References

Provider Requirements, Authorization, and Documentation

Policy Background and Scope

Key Definitions