Home Births Form

CLINICAL POLICY CP.FC.21 Home Birth

Clinical Policy: Home Births Reference Number: CP.FC.21 Coding Implications
Last Review Date: 02/25 Revision Log All LOB Except Medicare

See Important Reminder at the end of this policy for important regulatory and legal information.

Description A planned home birth is an elective alternative to delivery in a birthing center or hospital setting. Women are encouraged to make medically informed decisions about home delivery, and provision of home births will be considered when coverage is mandated by law or member’s benefit language.

Definition The practice of the profession of midwifery The practice of the profession of midwifery is defined as the management of normal pregnancies, child birth and postpartum care as well as primary preventive reproductive health care of essentially healthy women as specified in the written practice agreement, and shall include newborn evaluation, resuscitation and referral for infants. Since coverage of a midwife is included within maternity care, New York Insurance Law § 4303(c)(1), it is covered under Healthy New York. Regulation of midwifery is primarily under the auspices of the New York State Education Department, pursuant to the New York Education Law (McKinney 2001 and 2005 Supplement) and the regulations promulgated thereunder. A licensed midwife shall have the authority, as necessary, and limited to the practice of midwifery, and subject to limitations in the written agreement, to prescribe and administer drugs, immunizing agents, diagnostic tests and devices, and to order laboratory tests, as established by the board in accordance with the commissioner's regulations.

Policy/Criteria I. It is the policy of health plans affiliated with Fidelis Care® that home births are medically necessary when the following criteria are met: A. Elective Home Births performed by a participating Certified Nurse Midwife (CNM), Family Practitioner (FP), or Obstetrician/Gynecologist (Ob/Gyn) do not require prior authorization. B. Home Birth requests from Non-participating providers or providers who do not fall into one of the three (3) disciplines noted above require prior authorization. C. The birth is overseen by a provider of the Plan who meets one of the following criteria:

1. If home birth services are being managed by a midwife, all of the following criteria must be met: a. The midwife must be licensed in the State of New York, certified by the American Midwifery Certification Board (or its predecessor organizations) or the certified nurse–midwife’s, certified midwife’s, or midwife’s education and licensure meet International Confederation of Midwives Global Standards for Midwifery Education b. The midwife must have a written agreement providing for physician

CLINICAL POLICY CP.FC.21 Home Birth

consultation, collaboration, referral, and emergency obstetrical coverage with a licensed, board certified obstetrician-gynecologist, OR a licensed physician who practices obstetrics and has obstetric privileges at a hospital, OR a hospital that provides obstetric services through a licensed physician having obstetrical privileges at such institution c. There is a written plan for emergency care including documentation for timely emergency transportation to the nearest appropriate hospital for an emergency condition

2. If home birth services are being managed by a physician, all of the following must be met: a. The physician practices obstetrics within an integrated and regulated health system b. If the physician is not an obstetrician or family practice physician that has completed an obstetrics fellowship, there is documented proof of back-up supervision and coverage by a board certified or an active candidate for certification by the American Board of Obstetrics and Gynecology c. Emergency care is planned at a facility where the supervising obstetrician has admitting privileges d. There is a written plan for emergency care including documentation for timely emergency transportation to the nearest appropriate hospital for an emergency condition D. No preexisting medical condition(s) that increase pregnancy risk E. No prior cesarean delivery F. Absence of significant disease during pregnancy G. A singleton pregnancy H. Fetal presentation is cephalic I. Spontaneous labor in a pregnancy that has lasted at least 37 weeks but no more than 41 weeks J. There is a preexisting arrangement for emergency transportation to a nearby hospital if needed. K. No plan for pharmaceutical induction or augmentation

   II. It is the policy of health plans affiliated with Centene Corporation that home births are considered not medically necessary for any circumstances other than those specified above.

   Background Home birth remains a controversial issue, with safety as the primary focus. Although many countries have established lists based on specific patient characteristics and risks that might compromise the safety of out of hospital births, no specific list exists for the United States. Planned home birth must include a system that allows for collaboration, and referral and transfer to hospital care if problems arise. Appropriate risk screening is paramount in evaluating which home births may lead to positive outcomes. 3, 7

   American College of Obstetricians and Gynecologists (ACOG) ACOG does not support planned home births given the published medical data and believes that hospitals and birthing centers are the safest settings for birth. However, ACOG respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. This

CLINICAL POLICY CP.FC.21 Home Birth

includes the appropriate selection of candidates for home birth; the appropriate certification for midwifes, as noted in the policy statement; practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. Specifically, women should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. 3

American Academy of Pediatrics (AAP) The most recent policy statement concurs with ACOG, affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery. In addition, in the United States, the AAP recommends that the delivery be attended by at least two individuals, one who has primary responsibility for the mother and one who has primary responsibility for the infant.1

American College of Nurse Midwives & American Public Health Association These two organizations have policy statements supporting the practice of planned out-of- hospital birth in select populations of women.2, 4

World Health Organization A recent policy statement indicates that women can choose to deliver at home if they have low- risk pregnancies, receive the appropriate level of care, and formulate contingency plans for transfer to a properly-staffed/equipped delivery unit if problems arise. 9

A meta-analysis was completed comparing maternal and newborn outcomes in planned home birth versus planned hospital births. Planned home births were associated with fewer maternal interventions including labor induction or augmentation, regional analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery. These women were less likely to experience lacerations, and infections. Neonatal outcomes of planned home

CLINICAL POLICY CP.FC.21 Home Birth

births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates. 3, 12

In the Netherlands and the United Kingdom, some large observational studies suggest that elevated neonatal mortality rates were associated with first time births in the home versus other birth settings, and that multiparous, low-risk births at home did not have an increased risk of maternal or neonatal complications.13, 14 In contrast, a retrospective cohort study of Canadian patients found no risk of increased adverse neonatal outcomes for infants of primiparous or multiparous women with planned home births, and for both primiparous and multiparous women, rates of intrapartum interventions were lower.15 A prospective study in the Netherlands similarly found no increased risk of perinatal complications for infants of primiparous women planning to deliver at home, and for infants of multiparous women, planned home delivery resulted in significantly better perinatal outcomes.16

There is a paucity of randomized, controlled trials of planned home birth. Most information on planned home births comes from observational studies, which are often limited by methodological problems, including small sample sizes, lack of an appropriate control group, reliance on voluntary submission of data or self-reporting, limited ability to distinguish accurately between planned and unplanned home births, variation in the skill, training, and certification of the birth attendant, and an inability to account for and accurately attribute adverse outcomes associated with antepartum or intrapartum transfers.6, 10

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT® Codes Description 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

HCPCS Codes Description N/A

CLINICAL POLICY CP.FC.21 Home Birth

ICD-10-CM Diagnosis Codes that Support Coverage Criteria ICD-10-CM Code Description O80 Encounter for full-term uncomplicated delivery

Reviews, Revisions, and Approvals Date Approval Date Major revision incorporating Centene Home Birth Policy Criteria 7/20 7/20 Annual review. Added to I.A.2.b an option for family practice physicians ; 2/22

Annual review; references updated 2/23

Annual review; references updated 2/24

Annual review. Added “except Medicare” to policy header. Removed from sections C1.c. and 2d. Criteria for 15 minute transport to hospital and reworded to “There is a written plan for emergency care including documentation for timely emergency…” References reviewed and updated. 2/25

References

1. Centene Clinical Policy CP.MP.136 Home Births, Version 1/2024.
2. New York Insurance Law § 4303(c)(1) (McKinney 2000 and 2005 Supplement) New York Department of Financial Services (April 2005). Maternity Care Coverage. Retrieved from: https://www.dfs.ny.gov/insurance/ogco2005/rg050409.htm
3. American College of Obstetricians and Gynecologists. Planned Home Birth. Committee Opinion No.
4. Published April 2017 (reaffirmed 2023). Accessed February 12, 2025.
5. Declercq E, Stotland NE. Planned home birth. UpToDate. www.uptodate.com. Updated March 13,
6. Accessed February 12, 2025.
7. Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned Out-of-Hospital Birth and Birth Outcomes. N Engl J Med. 2015;373(27):2642 to 2653. doi:10.1056/NEJMsa1501738
8. Watterberg K; COMMITTEE ON FETUS AND NEWBORN. Providing Care for Infants Born at Home. Pediatrics. 2020;145(5):e20200626. doi:10.1542/peds.2020-0626
9. American College of Nurse-Midwives. Position Statement: Planned Home Birth. Published December
10. (Updated December 2016). https://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000251/Planne d-Home-Birth-Dec-2016.pdf. Accessed February 12, 2025.
11. American Public Health Association. Increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC 2001. https://apha.org/policies-and- advocacy/public-health-policy-statements/policy-database/2014/07/09/11/29/increasing-access-to-out- of-hospital-maternity-care-services-through-regulated-direct-entry-midwives.
12. Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343;d7400. Published 2011 Nov 243. doi:10.1136/bmj.d7400
13. de Jonge A, van der Goes BY, Ravelli AC, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG. 2009;116(9):1177 to 1184. doi: 10.1111/j.1471-0528.2009.02175.x
14. Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ. 2016;188(5):E80 to E90. doi:10.1503/cmaj.150564

CLINICAL POLICY CP.FC.21 Home Birth

12. Wiegers TA, Keirse MJ, van der Zee J, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ. 1996;313(7068):1309 to 1313. doi:10.1136/bmj.313.7068.1309
13. Bachilova S, Czuzoj-Shulman N, Abenhaim HA. Effect of Maternal and Pregnancy Risk Factors on Early Neonatal Death in Planned Home Births Delivering at Home. J Obstet Gynaecol Can. 2018;40(5):540 to 546. doi:10.1016/j.jogc.2017.07.029
14. Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health 2014;59(1):17 to 27. doi:10.1111/jmwh.12172
15. Grünebaum A, McCullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006 to 2009. Am J Obstet Gynecol. 2014;211(4):390.e1 to 390.e3907. doi:10.1016/j.ajog.2014.03.047
16. Olsen O, Clausen JA. Planned hospital birth compared with planned home birth for pregnant women at low risk of complications. Cochrane Database Syst Rev. 2023;3(3):CD000352. Published 2023 Mar 8. doi:10.1002/14651858.CD000352.pub3
17. Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol. 2013;208 (1):31 to 38. doi:10.1016/j.ajog.2012.10.002
18. Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home births vs planned hospital births: a metaanalysis [published correction appears in Am J Obstet Gynecol. 2011 Apr;204(4):e7 to 13]. Am J Obstet Gynecol. 2010;203(3):243.e1 to 243.e2438. doi:10.1016/j.ajog.2010.05.028
19. American Academy of Pediatrics. Planned Home Birth. Pediatrics. 2013;131(5):1016 to 1020. https://publications.aap.org/pediatrics/article/131/5/1016/31324/Planned-Home- Birth?autologincheck=redirected. Published May 2013. Accessed February 12, 2025.

20. American Academy of Pediatrics. American Academy of Pediatric issues safety recommendations on home births; hospitals remain the safest option even amid coronavirus pandemic. Accessed at https://www.healthychildren.org/English/news/Pages/Hospitals-Remain-the-Safest-Option-for-Birth- Even-Amid-COVID-19.aspx. Published April 20, 2020. Accessed February 12, 2025.

    Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Fidelis Care.

    The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy,

CLINICAL POLICY CP.FC.21 Home Birth

contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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