Home Birth Midwifery Services Form

Home Birth Midwifery Services

Definitions1

1. Certified nurse-midwife (CNM) — an individual educated in the 2 disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse Midwives (ACNM).
2. Certified midwife (CM) — an individual educated in the discipline of midwifery, who possesses evidence of certification according to the requirements of ACNM.
3. Midwifery practice — the independent management of women’s healthcare as practiced by CNMs and CMs, focusing particularly on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecologic needs of women.

4. High risk pregnancy — Pregnancy in which the mother, fetus, or newborn is or will be at increased risk for morbidity or mortality before or after delivery.

   1Regulation of midwifery is primarily under the auspices of the New York State Education Department. The rules and regulations pertaining to midwifery may be found at: Article 140, Midwifery: https://www.op.nysed.gov/professions/midwifery/laws-rules- regulations/article-140

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10. Multiple pregnancies (> 1 fetus)
11. Poor obstetrical history, including but not limited to the following:  Perinatal mortality  Preterm labor  Preterm delivery or small for gestational age delivery  Fetal growth restriction  Fetal malformation  Placental malposition  Preeclampsia and/or chronic hypertension  Maternal hemorrhage  History of complications at the time of delivery in a previous pregnancy including history of shoulder dystocia or postpartum hemorrhage (i.e., blood loss ≥ 1000mL after delivery)  Prior third- or fourth-degree lacerations
12. Previous successful vaginal birth after cesarean section (VBAC)
13. Pregnancy complications, including but not limited to the following:  Gestational age < 37 or > 41 weeks  Third trimester bleeding  Oligohydramnios or polyhydramnios  Breech or other fetal malpresentation  Fetal macrosomia  Alloimmunization  Prolonged rupture of membranes  Prolongation of first and/or second stages of labor  Non-reassuring fetal surveillance  Severe anemia during pregnancy
14. Pregnancy resulting from infertility / assisted reproductive technology services
15. Exposure to teratogens (i.e., cigarette smoking, alcohol, drug addiction/substance abuse)
16. The inability for a timely transfer and not having an existing arrangement with a hospital for such transfer
    Limitations and Exclusions
17. Midwives must be ACNM-certified (or certified by the American Midwifery Certification Board [AMCB], formerly the American College of Nurse Mid-Wives Certification Council, Inc. [ACC]) and licensed by New York.
18. Midwives must carry professional liability or medical malpractice insurance.
19. The use of doula services, while supportive, is not supported by scientific literature as being required for delivery and is therefore not considered medically necessary.
20. Coverage will not be provided for duplicative routine services provided by both a licensed midwife and a participating physician. In this case, the physician services will supersede those of the midwife.

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Page 4 of 5 Procedure Codes
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59414 Delivery of placenta (separate procedure) 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure)

Revision History Company(ies)

  DATE

REVISION EmblemHealth Jun. 13, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Jun. 14, 2024 High-risk section changes:

• Girls < 15 years of age changed to < 18, women > 40 changed to ≥ 40
• Placental “accidents” changed to “malposition”
• “and/or chronic hypertension” added to preeclampsia
• Removed “requiring iron transfusion” from severe anemia
• Added the inability for a timely transfer and not having an existing arrangement with a hospital for such transfer EmblemHealth Jul. 8, 2020 Added poor obstetrical history examples

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Page 5 of 5 EmblemHealth Jun. 8, 2018 Added examples to high-risk condition/clinical scenario listings