CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage Exclusions — Non‑covered Services (Plastic/Reconstructive and related)

Lists services, devices, procedures, and items considered non‑covered or investigational across Medicaid (excl. EFP), INTEGRITY, and Commercial lines; informs provider reimbursement and prior authorization expectations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage Exclusions — Non‑covered Services (Plastic/Reconstructive and related)

Policy CodePolicy N/A

Change TypeCode list updates

Effective DateN/A

Next Review DateN/A

Key ActionCheck plan-specific non-covered CPT/ICD-10/HCPCS lists and obtain prior authorization when required; do not expect coverage for codes explicitly listed as non-covered.

SourceLink

POLICY UPDATE CHANGES

Policy revised to add CPT 95941 to INTEGRITY and Commercial Non Covered Grid effective 11/1/22.

Annual policy review and codes added/removed to CPT/HCPC list.

3lines of business named in scope

~40+explicitly listed cosmetic or exclusion items/ procedures

~250number of CPT/HCPCS/other codes listed as non-covered

hundredsindividual CPT/HCPCS/modifier codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

chunks containing code lists

Coverage Criteria and Exclusions

Coverage Criteria and Exclusions — Summary

COVERAGE CRITERIA — Investigational / Exclusions (cosmetic, investigational, DME, infertility, and additional explicit non-covered services). The lists below consolidate exclusions from Neighborhood Health Plan of Rhode Island policy source material. Items or services listed are not covered unless otherwise noted in covered services or required by law.

ALL of the following

Cosmetic Services: Procedures or services that change or improve appearance without significantly improving physiological function are not covered (examples listed below).
Investigational or Experimental Services: Drugs, devices, or treatments lacking FDA approval; services that are the subject of Phase I/II clinical trials or investigational arms of Phase III; services delivered in connection with non-covered items; routine services associated with investigational cancer treatment are an exception per state regulation.
DME Exclusions: Purchase, repair, or replacement due to member abuse, theft or destruction (unless documentation provided), repair of non-covered DME, repair of items covered under warranty, and repair of rented DME are not covered.
Infertility / Reproductive Exclusions: Home ovulation kits, services for members not meeting infertility definition, experimental infertility procedures, surrogacy costs, long-term cryopreservation (>90 days) except when in active treatment or specific medical conditions, donor recruitment/compensation, donor sperm/lab services absent diagnosed male factor infertility, procurement of frozen donor oocytes, services necessary due to voluntary sterilization or unsuccessful reversal, and related exclusions listed in policy.
Additional Explicit Exclusions: See policy lists for items such as Lasik, wigs (except alopecia and cancer), medical marijuana, health club memberships, transportation by chair car/wheelchair van/taxi, electrolysis, chronic care management services, and provider charges for missed appointments, among others.

Investigational or Experimental Exclusions

COVERAGE CRITERIA — Investigational/Experimental Exclusions — Services are investigational/experimental and not covered when:

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

COVERAGE CRITERIA — DME Exclusions — DME is not covered in these circumstances:

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 is provided (explanation of continuing medical necessity, explanation that item was stolen or 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.

Infertility / Reproductive Exclusions

COVERAGE CRITERIA — Infertility / Reproductive Exclusions — Infertility services not covered when any of the following apply:

Home ovulation prediction kits.

Members who do not meet the definition of Infertility.

Experimental infertility procedures.

The costs of surrogacy, including all costs incurred by a fertile woman to achieve a pregnancy as a surrogate or gestational carrier, including drugs for implantation, embryo transfer, cryopreservation, maternity care for a surrogate who is not a member, donor recruitment and compensation.

Long-term (longer than 90 days) sperm or embryo cryopreservation unless the member is in active infertility treatment. Short-term (<90 days) may be authorized for certain medical conditions.

Not Covered / Exclusions — Detailed List

COVERAGE CRITERIA — Not covered / Exclusions — Services listed below are explicitly excluded from coverage unless an exception is noted elsewhere in the plan:

Cosmetic procedures and surgeries (examples include cervicoplasty, chemical peels/exfoliations/dermabrasions, correction of variations in normal anatomy such as augmentation mammoplasty and mastopexy, cosmetic prosthetic devices, excision of excess skin including brachioplasty and abdominoplasty (except panniculectomy), genioplasty, gynecomastia surgery, hair removal and transplants, inverted nipple surgery, laser treatment for acne/acne scars, liposuction, osteoplasty, otoplasty, rhinoplasty, rhytidectomy, scar revision, sclerotherapy for spider veins, subcutaneous injection of filling material, tattooing/tattoo removal (except nipple/areola related to mastectomy), testicular prosthesis surgery, treatment of vitiligo, scalp hair prostheses/wigs except as noted).

Additional exclusions: Academic performance testing; adult respite care (except hospice); air conditioners; air purifiers/HEPA filters; altered auditory feedback devices; chronic care management services; dehumidifiers; diagnostic tests to evaluate need for noncovered service; drugs/devices to treat sexual/erectile dysfunction (except medically necessary for organic conditions); educational testing/training; food products for specialty diets; health club memberships; medical marijuana; personal emergency response systems; planned home births; services outside the U.S.; sperm banking (subject to specific infertility rules); standard car seats; trampolines; vocational rehabilitation; waterproof casts; wigs (except alopecia and cancer); and many other items as listed in policy.

Network Restrictions: Services must be rendered by network providers unless emergency or prior approval received; services in nonconventional settings (spas/resorts, wilderness programs, etc.) are excluded even if provided by licensed providers.

Non-Covered CPT Codes (Commercial & Integrity consolidated)CPTNot Covered

89267-89272	Semen analysis related codes (included in non-covered list)
89290-89300	Assisted reproductive laboratory and related specimen handling (included in non-covered list)
89329-89330	Embryo culture/transfer related codes (included in non-covered list)
89342-89398	Assisted reproductive technology laboratory procedures (included in non-covered list)
93792-93793	Cardiac rehab / remote monitoring codes noted as non-covered in commercial list
98970-98972	Digital E/M remote evaluation/virtual check-in services (listed non-covered)
98975-98977	Remote patient monitoring device supply/training codes (listed non-covered)
98980-98981	Remote therapeutic monitoring codes (listed non-covered)
99421-99423	Online digital E/M services (non-covered per commercial list)
99446-99458	Interprofessional telephone/online/consultation codes (non-covered per commercial list)

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Non-Covered Codes and Modifiers

Non-covered CPT/HCPCS/CPT-T and other codes (partial list)mixedNot Covered

0001U	listed in Medicaid Non-Covered CPT codes
0002M	listed in Medicaid Non-Covered CPT codes
0002U	listed in Medicaid Non-Covered CPT codes
0217T	listed in Non-Covered CPT/T codes
A0170	listed in Non-Covered HCPCS
C1734	listed in Non-Covered HCPCS
E0215	listed in Document History code lists
G0008	listed in Document History code lists
0490T	listed in Document History code lists
15769	listed in Document History code lists

1–10 of 20

1/2

Non-covered ModifiersModifierNot Covered

EY	listed as non-covered modifier
GC	listed as non-covered modifier
GL	listed as non-covered modifier
MS	listed as non-covered modifier

Non-covered CPT Codes (Document History group)CPTNot Covered

0012M	CPT Codes listed (partial list shown)
0013M	CPT Codes listed (partial list shown)

Non-covered HCPCS Codes (Document History group)HCPCSNot Covered

A0380	HCPCS codes listed (partial)
A0394	HCPCS codes listed (partial)

Non-covered ModifiersModifierNot Covered

EY	Modifiers listed as non-covered (partial)
GL	Modifiers listed as non-covered (partial)

ICD-10 Diagnosis Codes referenced as non-coveredICD-10Not Covered

N46.01 to N46.9	ICD-10 diagnosis codes listed
N97.0 to N97.9	ICD-10 diagnosis codes listed

Non-Covered CPT Codes (partial chunk)CPTNot Covered

81465
81470
81471
81514
81521
81539
81541
81551
81560
81595

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Non-Covered HCPCS / other codes (continued)HCPCSNot Covered

G0572
G1000-G1011
G1024-G1028
G2000-G2015
G2020
G2021
G2022
G2025
G2058-G2083
G2086-G2125

1–10 of 42

1/5

Additional Non-Covered HCPCS / T/V/Q/S codesHCPCSNot Covered

M1072-M1089
M1094-M1105
P2028-P2038
P9603
P9604
Q2034-Q2039
Q2041
Q2042
Q4112-Q4114
Q4125

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Modifiers listed as Non-Covered (no modifiers shown)Modifier

No codes listed

No clinical thresholds — coding note

Clinical thresholdsNo clinical thresholds are provided for the CPT/HCPCS/modifier code lists in this policy.

Implication for prior authorizationCodes listed as Non-Covered Services are identified as not covered; prior authorization is not applicable to codes explicitly listed as non-covered.

Where referencedSee 'Non-Covered Services: Commercial' sections containing extensive CPT and HCPCS code lists (chunks 72–74).

Provider Actions, Prior Authorization, and Denial Risks

Prior Authorization

Prior Authorization Required

Except as explicitly covered elsewhere, cosmetic procedures and services performed solely to change or improve appearance are not covered. Providers must document medical necessity when a normally cosmetic service is being billed as medically necessary; absent clear documentation of medical necessity, claims for cosmetic procedures are likely to be denied.

Examples of non-covered cosmetic services include (but are not limited to): cervicoplasty; chemical peels; augmentation mammoplasty and other breast contouring; cosmetic prosthetics; excision of excess skin (e.g., abdominoplasty) except panniculectomy when allowed; genioplasty; gynecomastia surgery; hair removal/transplants; laser treatment for acne/scars; liposuction; otoplasty; rhinoplasty; rhytidectomy; scar revision; sclerotherapy; subcutaneous filler injections; tattooing/tattoo removal (except nipple/areola tattooing post-mastectomy); testicular prosthesis; treatment for vitiligo.
title":"Noncoverage of Cosmetic Procedures","type":"callout","variant":"denial_risk"},{

Prior Authorization

Prior authorization requirements

Services must be rendered by network providers unless it is an emergency or prior approval has been obtained. Prior authorization is recommended or required for certain services (for example some infertility-related services, short-term cryopreservation, donor cycles, and other high-cost or specialized treatments). Requests for services from non-network providers should include documentation supporting the need for non-network care and prior approval.

Background

Cosmetic procedures are defined in the background of this policy as services that change or improve appearance without significantly improving physiological function. The policy distinguishes cosmetic services from medically necessary care and lists examples of cosmetic procedures that are excluded from coverage.

The background establishes that the document provides exclusion lists and definitions to guide coverage determinations and to inform providers about services that are generally not reimbursed when performed for aesthetic purposes.

Definitions

Cosmetic Procedure — definition

DefinitionCosmetic Procedure: Procedures or services that change or improve appearance without significantly improving physiological function.

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

Examples includedExamples listed include cervicoplasty, chemical peels, augmentation mammoplasty, excision of excess skin (e.g., abdominoplasty), genioplasty, gynecomastia surgery, hair removal/transplants, liposuction, and osteoplasty.

Cosmetic Surgery — ASPS definition (policy reference)

ASPS definitionCosmetic Surgery: Defined by the American Society of Plastic Surgeons as surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self‑esteem.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage Exclusions — Non‑covered Services (Plastic/Reconstructive and related)

Policy CodePolicy N/A

Change TypeCode list updates

Effective DateN/A

Next Review DateN/A

Key ActionCheck plan-specific non-covered CPT/ICD-10/HCPCS lists and obtain prior authorization when required; do not expect coverage for codes explicitly listed as non-covered.

SourceLink

On This Page

Infertility services necessary for conception as a result of voluntary sterilization or following unsuccessful reversal of voluntary sterilization; reversal procedures are excluded.

Donor sperm and associated laboratory services in absence of diagnosed male factor infertility in the partner; procurement of frozen donor oocytes; drugs for anonymous or designated egg donors related to stimulated ART cycles unless member is sole recipient.

Transportation: Transportation by chair car, wheelchair van, or taxi is excluded.

Prior authorization is recommended for certain infertility services and for short-term cryopreservation; prior auth may be required for donor cycles and other ART-related services.
Non-network services require prior approval except in emergencies.

Billing Rule

Check plan-specific non-covered code lists

Consult the plan-specific Non‑Covered Services code lists before submitting claims. These lists identify CPT, HCPCS, ICD-10, and modifier codes that the plan explicitly excludes and are not exhaustive — providers should verify the appropriate list for the member's payer (Medicaid, INTEGRITY, Commercial).

Medicaid Non-Covered Codes: see document page referenced for Medicaid list.
INTEGRITY Non-Covered Codes: see document page referenced for INTEGRITY list.
Commercial Non-Covered Codes: see Commercial Non-Covered lists (document pages referenced).

Billing Rule

Non-Covered Codes — Prior Authorization not applicable

Codes that appear on a plan's Non‑Covered Services list are explicitly not coverable. Prior authorization does not apply to codes that are identified as non‑covered — do not submit prior authorization requests expecting coverage for codes that are listed as non‑covered.

Non‑covered CPT/HCPCS codes (examples appear in the document history and non‑covered sections for each plan).
Prior authorization is not a remedy for codes explicitly listed as non‑covered.

Denial Risk

Investigational/Experimental denial risk

Requests for investigational or experimental services (including drugs or devices without FDA approval, services associated with investigational clinical trials, or services delivered in connection with non‑covered items) may be denied as investigational/experimental. Exception: routine services associated with investigational cancer treatments may be covered per state regulation.

Includes drugs/devices lacking FDA approval and treatments in Phase I/II trials or investigational arms of Phase III.
Routine services tied to investigational cancer treatment may be covered per state law.

Denial Risk

Setting and cosmetic denial risks

Some services will be denied if provided in settings that are not approved by the plan. For example, circumcisions performed outside a hospital, day surgery, or physician office may be denied. Services, programs, supplies, or procedures provided in nonconventional settings (e.g., spas/resorts, educational/recreational programs, wilderness camps) are excluded unless prior approval is obtained.

Circumcisions must be performed in hospital, day surgery, or physician office to be covered.
Examples of excluded nonconventional settings: spas/resorts, outward bound/wilderness programs, educational or recreational settings.

Denial Risk

Denial risk from non-covered codes

Billing codes listed on the Non‑Covered Services pages for each plan may trigger claim denials. Providers should not expect reimbursement for services billed using codes that appear on the plan's non‑covered lists.

Non‑covered code lists are plan‑specific and found on the document pages referenced (Medicaid, INTEGRITY, Commercial).
Lists are not necessarily exhaustive — if in doubt, confirm coverage or submit a prior authorization only when appropriate.

Documentation Required

DME loss/theft documentation

For DME that is stolen or destroyed, provide documentation to support replacement or reimbursement. Required documentation includes an explanation of continuing medical necessity, an explanation that the item was stolen or destroyed, and a copy of a police, fire department, or insurance report if applicable. Items resulting from member abuse and items covered under warranty or rented DME repairs are not payable.

Required documentation for stolen/destroyed DME: explanation of continuing medical necessity; explanation of theft/destruction; police/fire/insurance report copy if available.
DME not covered: items due to member abuse, items covered under provider/manufacturer warranty, and rented DME repair.

Note

Reference code lists

Reference the Non‑Covered Services lists and the document history/code lists before submitting claims. The policy's document history and non‑covered sections enumerate many CPT/HCPCS/ICD codes and modifiers; providers should consult the specific list that applies to the member's payer.

Medicaid, INTEGRITY, and Commercial non‑covered code sections are listed in the document — see the referenced pages for full code sets.
Document history contains enumerated codes; verify current lists prior to billing.

Documentation Required

Documentation for non-covered services

There are no additional special documentation requirements listed for services that are simply identified as non‑covered beyond referencing the non‑covered lists; however, when seeking coverage exceptions or when a normally excluded service is claimed as medically necessary, include thorough clinical documentation, rationale for medical necessity, and any supporting reports or prior authorization approvals.

When requesting an exception or prior authorization for a typically non‑covered service, include clinical notes, relevant diagnostic results, and rationale tying the service to medical necessity.
Claims for non‑covered services without supporting documentation or authorization are likely to be denied.

Procedures meeting this ASPS definition are considered cosmetic and, except as described in covered services, are not covered by the plan.

Contextual examplesThe document lists many procedures characterized as cosmetic surgery (e.g., rhinoplasty, rhytidectomy, augmentation mammoplasty, abdominoplasty).

Cosmetic Procedure — alternate entry

Alternate wordingCosmetic Procedure: Procedures or services that change or improve appearance without significantly improving physiological function (policy repeats this definition in multiple sections).

Policy effectServices fitting this definition are enumerated in exclusion lists and are treated as non‑covered unless expressly listed as covered elsewhere.

Common listed itemsListed items include chemical exfoliations/peels, cervicoplasty, liposuction, hair removal/transplant, and correction of variations in normal anatomy (e.g., breast augmentation/reduction).

Cosmetic Surgery — alternate/duplicate ASPS definition

Alternate ASPS entryCosmetic Surgery (ASPS): Per the American Society of Plastic Surgeons, surgery performed to reshape normal structures of the body to improve appearance and self‑esteem — reiterated in policy text.

Repeated policy noteThe ASPS definition is cited verbatim in multiple policy sections to define excluded cosmetic surgery services.

Examples reiteratedExamples reiterated across sections include abdominoplasty, gynecomastia surgery, genioplasty, and osteoplasty.