CurrentAmbetter NevadaPolicy CP.MP.136

Clinical Policy: Home Births

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Defines medical necessity criteria and coverage considerations for planned home births for members/enrollees of the health plan, including required provider qualifications, patient risk criteria, and emergency planning.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Home Births

Policy CodePolicy CP.MP.136

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when applicable confirming provider credentials, a written emergency transfer plan with ≤15-minute transport, two planned attendants including an NRP-certified infant caregiver, and documentation of low-risk pregnancy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 minmax transport time

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CurrentAmbetter NevadaPolicy CP.MP.136

Clinical Policy: Home Births

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Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Home Births

Policy CodePolicy CP.MP.136

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 minmax transport time

37–40wgestational window

singletonpregnancy plurality

excludedprior uterine surgery

Medical Necessity and Coverage Criteria

Medical necessity criteria

Home births are medically necessary when ALL of the following groups of criteria are met:

Provider oversite

Midwife qualifications: Midwife must be certified by the American Midwifery Certification Board (or predecessor) or have education/licensure that meets International Confederation of Midwives Global Standards and be practicing within an integrated and regulated health system; the written emergency care plan must document that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition.
Physician qualifications: Physician must practice obstetrics within an integrated and regulated health system; if not an obstetrician or a family physician who completed an obstetrics fellowship, there must be documented back-up supervision/coverage by a board-certified or active candidate for certification by the American Board of Obstetrics and Gynecology; emergency care must be planned at a facility where the supervising obstetrician has admitting privileges; the written emergency care plan must document that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition.

Attendance: Two care providers planned to be present at the birth: one with primary responsibility for the birthing individual, and one with primary responsibility for the infant who is certified in the Neonatal Resuscitation Program (NRP) and has equipment to perform full neonatal resuscitation in accordance with NRP principles.

Low-risk pregnancy: Documented low-risk pregnancy including: singleton pregnancy with appropriate dating confirmed by ultrasound; anatomy ultrasound with no evidence of abnormalities; fetal presentation cephalic (vertex); planned spontaneous labor between 37 0/7 and 40 6/7 weeks; no prior cesarean delivery; no prior uterine surgery (e.g., myomectomy entering the myometrium); no preexisting medical conditions that increase pregnancy risk; and no complications during pregnancy.

The American College of Obstetricians and Gynecologists (ACOG) identifies several absolute contraindications to planned home birth that must be excluded before a home birth is considered. These include fetal malpresentation, multiple gestation, and prior cesarean delivery. The policy therefore requires confirmation of a singleton, cephalic presentation and no history of prior cesarean or other uterine surgery as part of establishing eligibility for planned home birth.

Operationally, if the member’s clinical situation does not meet all of the explicit medical necessity criteria in this policy, the service is considered Not Medically Necessary. Note that the policy’s prior broader "not medically necessary" section was removed and the current policy defines medical necessity by the explicit criteria groups; failure to satisfy those criteria is the basis for a Not Medically Necessary determination.

Coding and Clinical Limits

Referenced CPT CodesCPT

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)

HCPCSHCPCS

N/A	No HCPCS codes listed

inv-06: Emergency transport time — maximum planned transport time to hospital (<= 15 minutes).

Maximum planned transport time to hospitalEmergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition

Applies to midwife-managed careWritten emergency care plan must document transport ≤ 15 minutes for midwife-managed home births

Applies to physician-managed careWritten emergency care plan must document transport ≤ 15 minutes for physician-managed home births

inv-07: Gestational age window for planned home birth — between 37 0/7 and 40 6/7 weeks.

Gestational age windowPlanned spontaneous labor must be between 37 0/7 and 40 6/7 weeks

Confirming dating

Provider Requirements, Documentation, and Prior Authorization

Prior Authorization

Prior authorization must confirm provider credentials, 15-minute emergency transport plan, and two planned attendants

When prior authorization is required, the request must confirm that the attending provider is a participating, credentialed provider meeting the policy's midwife or physician qualifications; that a written emergency care/transport plan documents transport to the nearest appropriate hospital can be accomplished within 15 minutes of an emergency; and that two care providers are planned to be present including an NRP-certified attendant for the infant.

Attending provider meets midwife or physician-specific qualifications described in policy (see credentialing criteria).
Written emergency care plan documenting transport to nearest appropriate hospital ≤ 15 minutes.
Two planned attendants: one responsible for birthing individual and one NRP-certified for infant resuscitation with appropriate equipment.

Note

Provider action: confirm and document compliance with oversight, attendance, and low‑risk criteria

Providers must ensure the home birth plan and clinical documentation demonstrate adherence to the policy's attending-provider and attendance requirements and low‑risk pregnancy criteria; any applicable prior authorization should reflect these elements.

Background and Evidence

Planned home birth is an elective alternative to hospital or birthing center delivery and is associated with fewer maternal interventions (for example, less induction, regional analgesia, operative delivery, and cesarean) and lower rates of some maternal complications. However, published evidence has also associated planned home birth with increased risks for adverse neonatal outcomes, including a reported twofold to threefold increase in infant or neonatal mortality in some studies. National organizations (ACOG, AAP) do not endorse planned home birth as the safest option but recognize patient autonomy and emphasize careful candidate selection, appropriate provider qualifications, and systems to ensure timely transfer and readiness for neonatal resuscitation in the home setting.

Definitions

inv-13: Planned home birth — definition and required documented plan (attendants, emergency plan, location).

DefinitionAn elective delivery planned to occur in a home setting with a documented plan and participating credentialed provider oversight

Required attendantsTwo care providers planned: one responsible for the birthing individual and one responsible for the infant (NRP-certified) with full resuscitation equipment

Required emergency planA written emergency care plan documenting that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes

Location requirementDelivery is planned to occur in the member/enrollee's home (out-of-hospital setting) as the alternative to hospital or birthing center

inv-14: Low-risk pregnancy (for home birth eligibility) — singleton, cephalic, normal anatomy ultrasound, gestational age 37 0/7–40 6/7, etc.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Home Births

Policy CodePolicy CP.MP.136

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Singleton pregnancy with appropriate dating confirmed by ultrasound

Exclusion outside windowHome birth plan outside 37 0/7–40 6/7 weeks does not meet the documented low-risk pregnancy criteria

Evidence that the attending midwife or physician meets the specific qualifications in policy (see chunk 2).
Documentation of planned presence of two care providers including NRP-certified infant caregiver (see chunk 2).
Clinical documentation confirming low-risk pregnancy elements (see chunk 3).

Documentation Required

Required documentation to support medical necessity

Medical necessity documentation must include the attending provider's certification/licensure, a written emergency care/transport plan showing transport ≤ 15 minutes, evidence of two planned attendants (one NRP-certified for infant resuscitation), and documentation confirming the pregnancy meets low‑risk criteria.

For midwives: AMCB certification or education/licensure meeting ICM Global Standards and practice within an integrated, regulated health system (chunk 2).
For physicians: evidence of practicing obstetrics within an integrated, regulated health system and, if not an OB or family physician with OB fellowship, documented back-up supervision/coverage by a board-certified or active OB/GYN candidate (chunk 2).
Written emergency care plan documenting transport to the nearest appropriate hospital can be accomplished within 15 minutes (chunk 2).
Evidence of two planned care providers, including one NRP-certified attendant with full neonatal resuscitation equipment (chunk 2).
Documentation confirming low-risk pregnancy: singleton with dating by ultrasound, anatomy ultrasound without abnormalities, cephalic presentation, gestational age 37 0/7–40 6/7 weeks, no prior cesarean or uterine surgery, no preexisting conditions or complications (chunk 3).

Denial Risk

Denial triggers: missing provider qualifications, inadequate transfer planning, attendance, or low‑risk criteria

Services may be considered not medically necessary (denied) if documentation fails to demonstrate required provider qualifications, a written emergency transport plan capable of ≤ 15-minute transfer, planned presence of two qualified attendants (including NRP-certified infant caregiver), or the pregnancy does not meet the policy's low‑risk criteria.

Attending provider is not a participating/credentialed provider meeting the midwife or physician criteria (chunk 2).
No written emergency care/transport plan or plan does not document transport to appropriate hospital within 15 minutes (chunk 2).
Fewer than two planned care providers or no NRP-certified attendant for the infant (chunk 2).
Pregnancy does not meet low‑risk criteria (e.g., multiple gestation, non‑cephalic presentation, prior cesarean or uterine surgery, gestational age outside 37 0/7–40 6/7, ultrasound abnormalities, preexisting conditions, or complications during pregnancy) (chunk 3).

Singleton pregnancy required

Fetal presentationCephalic (vertex) presentation required

Ultrasound requirementsAppropriate dating confirmed by ultrasound and an anatomy ultrasound with no evidence of abnormalities

Gestational ageSpontaneous labor planned between 37 0/7 and 40 6/7 weeks

Prior uterine surgery and cesareanNo prior cesarean delivery and no prior uterine surgery (e.g., myomectomy entering the myometrium)