CurrentConnectiCarePolicy MG.MM.ME.29

Home Birth Midwifery Services

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Coverage and medical-necessity review for certified midwives providing home birth services throughout pregnancy, labor, birth, immediate postpartum care, and neonatal care up to 6 weeks, subject to credentialing, documentation, high-risk criteria, and timely hospital transfer capability.

Policy Summary

PayerConnectiCare

PolicyHome Birth Midwifery Services

Policy CodePolicy MG.MM.ME.29

Change TypeClinical and coverage criteria revision

Effective DateJune 12, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence demonstrating that the member meets the policy criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

High-risk conditions now include intrauterine growth restriction, placental abnormalities such as low-lying placenta or previa, and velamentous or marginal cord insertions.

The high-risk age criteria were revised to identify girls age 18 or younger and women age 40 or older at delivery.

The high-risk list was revised to identify placental malposition, preeclampsia and/or chronic hypertension, and the inability to arrange timely transfer to a hospital.

The revision history indicates that the severe-anemia criterion no longer includes a requirement for iron transfusion.

The policy content was transferred to an individual company-branded template.

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CurrentConnectiCarePolicy MG.MM.ME.29

Home Birth Midwifery Services

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Policy Summary

PayerConnectiCare

PolicyHome Birth Midwifery Services

Policy CodePolicy MG.MM.ME.29

Change TypeClinical and coverage criteria revision

Effective DateJune 12, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence demonstrating that the member meets the policy criteria for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

High-risk conditions now include intrauterine growth restriction, placental abnormalities such as low-lying placenta or previa, and velamentous or marginal cord insertions.

The high-risk age criteria were revised to identify girls age 18 or younger and women age 40 or older at delivery.

The high-risk list was revised to identify placental malposition, preeclampsia and/or chronic hypertension, and the inability to arrange timely transfer to a hospital.

The revision history indicates that the severe-anemia criterion no longer includes a requirement for iron transfusion.

The policy content was transferred to an individual company-branded template.

6 weeksMaximum neonatal care period

≤18High-risk maternal age threshold

≥40High-risk maternal age threshold

BMI ≥35High-risk obesity threshold

7Applicable procedure codes

≥1000 mLPrior postpartum hemorrhage threshold

Covered Services and Exclusions

Covered home birth midwifery services

Covered when the service is within the maternity-cycle scope and the provider and safety requirements are met, subject to the member’s benefit plan and medical-necessity review.

Home birth midwifery coverage

Maternity-cycle scope
- Home birth and midwifery care are eligible throughout pregnancy, labor, birth, and the immediate postpartum period, including neonatal care not exceeding 6 weeks.Neonatal care ≤ 6 weeks
Provider requirements
- The midwife must be certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB), licensed by Connecticut, and carry professional liability or medical malpractice insurance.
Care coordination and safety
- The midwife is expected to maintain a collaborative relationship with licensed physicians, as necessary, and refer the member for appropriate physician management when warranted.
- A timely transfer to a hospital must be possible, with an existing arrangement for such transfer in place.
  Inability to arrange timely transfer may result in denial of planned home birth coverage.

High-risk conditions and denial of home birth

Planned home birth coverage may be denied when any high-risk condition or unsafe transfer circumstance is present.

High-risk conditions or unsafe transfer

Maternal characteristics
- Maternal age is 18 years or younger or 40 years or older at delivery; height is under 5 feet; prepregnancy weight is under 100 pounds; or clinically severe obesity is present with BMI ≥ 35.Age ≤ 18 or ≥ 40 years; height < 5 feet; prepregnancy weight < 100 pounds; BMI ≥ 35
  For women age 35–40, the policy states that home delivery may be safe when adequate genetic counseling and testing have occurred and no medical problems are present.
Maternal medical or surgical conditions
- Structural abnormalities of the genital tract or reproductive organs; fibroids; prior cesarean section or uterine surgery; or a medical or surgical condition that may be exacerbated by pregnancy or may increase maternal or fetal risk, including autoimmune, cardiovascular, pulmonary, renal or urinary, gastrointestinal, hepatic, hematologic, endocrine, connective-tissue, neurologic, neoplastic, infectious, or significant mental-health disorders.

Doula services are excluded as not medically necessary. Although doula services may be supportive, the policy does not consider them required for delivery.

Duplicative routine services are not covered when furnished by both a licensed midwife and a participating physician. In these circumstances, the participating physician’s services supersede the duplicative midwife services.

Planned home birth coverage may be denied when a high-risk condition is present or when timely hospital transfer cannot be arranged. Relevant risk factors include maternal age 18 or younger or 40 or older at delivery, height under 5 feet, prepregnancy weight under 100 pounds or BMI 35 or greater, significant maternal, fetal, or pregnancy conditions, poor obstetrical history, and gestational age under 37 or over 41 weeks.

Doula services are not considered medically necessary for delivery under this policy and are therefore excluded from coverage.

Applicable Codes and Clinical Thresholds

Covered CPT CodesCPTCovered

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)

Maternal age

Younger maternal ageAge 18 years or younger at delivery is identified as high risk.

Older maternal ageAge 40 years or older at delivery is identified as high risk.

Age 35–40Home delivery may be considered safe for women age 35–40 when adequate genetic counseling and testing have occurred and no medical problems are present.

Maternal height

Height thresholdHeight under 5 feet is identified as high risk.

MeasurementThe threshold applies to the member’s height in feet.

Prior Authorization and Provider Responsibilities

Prior Authorization

Prior Authorization Submission

The treating physician or primary care provider must submit the clinical evidence needed for ConnectiCare to review the request for prior authorization.

Submit the request and supporting clinical documentation through the treating physician or primary care provider.
Without the required documentation and information, ConnectiCare cannot properly review the prior authorization request.

Documentation Required

Clinical Evidence Required

Submit evidence demonstrating that the member meets the applicable coverage criteria for home birth midwifery services. Medical necessity does not guarantee payment if the member’s benefit plan excludes the service or imposes different requirements.

Include relevant clinical evidence addressing eligibility, risk factors, pregnancy status, and the proposed home birth plan.

Policy Scope

This policy addresses certified midwifery services for planned home birth throughout the maternity cycle: pregnancy, labor, birth, and the immediate postpartum period, including neonatal care for no more than 6 weeks. Home birth may be appropriate for low-risk members, while coverage may be denied when a high-risk pregnancy or condition makes home birth unsafe. Midwives are expected to maintain collaborative relationships with licensed physicians and refer members for physician management when clinically warranted.

Policy Definitions

Certified nurse-midwife (CNM)

Professional educationA certified nurse-midwife is an individual educated in the disciplines of nursing and midwifery.

Certification evidenceThe individual possesses evidence of certification.

Certifying requirementsCertification is according to the requirements of the American College of Nurse Midwives (ACNM).

Certified midwife (CM)

Professional educationA certified midwife is an individual educated in the discipline of midwifery.

Certification evidenceThe individual possesses evidence of certification.

Certifying requirements

Policy Summary

PayerConnectiCare

PolicyHome Birth Midwifery Services

Policy CodePolicy MG.MM.ME.29

Change TypeClinical and coverage criteria revision

Effective DateJune 12, 2026

Next Review DateNot specified

Key ActionSubmit clinical evidence demonstrating that the member meets the policy criteria for prior authorization review.

SourceLink

On This Page

Examples include hypertension, diabetes, lupus, Crohn’s disease, heart failure, genital herpes, and psychosis.

Fetal, membrane, or pregnancy conditions

Fetal or fetal-membrane abnormality; multiple pregnancy; gestational age under 37 weeks or over 41 weeks; third-trimester bleeding; oligohydramnios or polyhydramnios; breech or other fetal malpresentation; fetal macrosomia; alloimmunization; prolonged rupture of membranes; prolongation of the first or second stage of labor; non-reassuring fetal surveillance; severe anemia; intrauterine growth restriction; low-lying placenta or placenta previa; or velamentous or marginal cord insertion.Gestational age < 37 or > 41 weeks

Poor obstetrical history

Prior perinatal mortality, preterm labor or delivery, small-for-gestational-age delivery, fetal growth restriction, fetal malformation, placental malposition, preeclampsia or chronic hypertension, maternal hemorrhage, prior delivery complications including shoulder dystocia or postpartum hemorrhage, or a prior third- or fourth-degree laceration.Prior postpartum hemorrhage: blood loss ≥ 1000 mL after delivery

Other risk factors

Previous successful vaginal birth after cesarean (VBAC); pregnancy resulting from infertility or assisted reproductive technology; exposure to teratogens, cigarette smoking, alcohol, drug addiction, or substance abuse; sexually transmitted disease, particularly genital herpes; or inability to arrange timely hospital transfer with an existing hospital-transfer arrangement.

Coverage implication

A height under 5 feet is included among the high-risk conditions that may support denial of planned home birth coverage.

Prepregnancy weight

Weight thresholdPrepregnancy weight under 100 pounds is identified as high risk.

BMI thresholdClinically severe obesity with a BMI of 35 or greater is identified as high risk.

Risk categoryThese prepregnancy weight factors are included among the high-risk conditions for planned home birth.

Gestational age

Early gestational ageGestational age under 37 weeks is identified as high risk.

Late gestational ageGestational age over 41 weeks is identified as high risk.

Clinical categoryGestational age outside the 37-to-41-week range is listed as a pregnancy complication.

Prior postpartum hemorrhage

Blood-loss thresholdBlood loss of 1,000 mL or more after delivery defines the prior postpartum hemorrhage threshold.

History categoryPrior postpartum hemorrhage is included under poor obstetrical history.

Delivery historyA history of postpartum hemorrhage is included among prior delivery complications that may indicate high risk.

Neonatal care

Included careThe maternity cycle includes pregnancy, labor, birth, and the immediate postpartum period.

Neonatal care limitNeonatal care included in the maternity-cycle services must not exceed 6 weeks.

Coverage scopeMidwifery services for home birth are covered throughout the maternity cycle, subject to the policy criteria.

The member’s benefit plan governs if it conflicts with this guideline; Medicare coverage may also differ under applicable CMS determinations.

Documentation Required

Provider Qualifications and Safety Arrangements

Before arranging home birth services, the provider must document appropriate qualifications and safety arrangements. Midwives are expected to maintain a collaborative relationship with licensed physicians, obtain physician management when warranted, and have an existing hospital arrangement that supports timely transfer if needed.

Document the responsible provider’s required certification, Connecticut licensure, and professional liability or medical malpractice insurance.
Maintain a collaborative relationship with licensed physicians and refer the member for appropriate physician management when warranted.
Document the hospital transfer arrangement and the ability to arrange timely transfer during an emergency.
Include the relevant qualifications, coverage, collaboration, and transfer information in the clinical submission for review.

Denial Risk

High-Risk Pregnancy or Unsafe Transfer

Home birth coverage may be denied when the pregnancy is high risk or when timely transfer cannot be arranged. Review the member’s history and current pregnancy for conditions that make home birth unsafe before submitting or approving the plan.

High-risk factors include age ≤18 or ≥40 at delivery, height <5 feet, prepregnancy weight <100 pounds or clinically severe obesity (BMI ≥35), genital or reproductive structural abnormalities, fibroids, and significant maternal medical or surgical conditions.
Consider prior cesarean or uterine surgery; autoimmune, cardiovascular, pulmonary, renal, urinary, gastrointestinal, hepatic, hematological, endocrine, connective-tissue, neurologic, or neoplastic disorders; infections; and significant mental health disorders.
Consider sexually transmitted disease—particularly genital herpes—fetal or membrane abnormality, multiple pregnancy, poor obstetrical history, prior VBAC, infertility or assisted reproductive technology, and teratogen exposure including smoking, alcohol, or substance abuse.
Pregnancy-related risks include gestational age <37 or >41 weeks, third-trimester bleeding, abnormal amniotic fluid, breech or other malpresentation, fetal macrosomia, alloimmunization, prolonged rupture of membranes, prolonged labor, non-reassuring fetal surveillance, severe anemia, growth restriction, placental abnormalities, and velamentous or marginal cord insertion.
Poor obstetrical history includes perinatal mortality, preterm labor or delivery, small-for-gestational-age delivery, fetal growth restriction or malformation, placental malposition, preeclampsia or chronic hypertension, maternal hemorrhage, prior shoulder dystocia or postpartum hemorrhage (blood loss ≥1000 mL), and prior third- or fourth-degree laceration.
Deny or do not proceed with home birth coverage when there is no existing hospital transfer arrangement or the provider cannot arrange timely transfer.

Documentation Required

Midwife Credentialing and Insurance

Midwives must meet the policy’s credentialing and insurance requirements before providing covered home birth services.

The midwife must be certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB), formerly the American College of Nurse-Midwives Certification Council, Inc. (ACC).
The midwife must be licensed in Connecticut.
The midwife must carry professional liability or medical malpractice insurance.

Billing Rule

Avoid Duplicative Routine Billing

ConnectiCare will not cover duplicative routine services provided by both a licensed midwife and a participating physician.

When routine services overlap, the participating physician’s services supersede the midwife’s services for coverage purposes.

Denial Risk

Doula Services Not Medically Necessary

Doula services may be supportive, but they are not considered medically necessary under this policy because the policy states that scientific literature does not establish them as required for delivery.

Do not submit doula services as medically necessary home birth midwifery services.

Certification is according to the requirements of the American College of Nurse Midwives (ACNM).

Midwifery practice

Practice modelMidwifery practice is the independent management of women’s healthcare by certified nurse-midwives and certified midwives.

Primary focusThe practice focuses particularly on pregnancy, childbirth, and the postpartum period.

Additional servicesIt also includes care of the newborn, family planning, and women’s gynecologic needs.

High-risk pregnancy

DefinitionA high-risk pregnancy is one in which the mother, fetus, or newborn is or will be at increased risk for morbidity or mortality.

Who may be affectedThe increased risk may involve the mother, the fetus, the newborn, or more than one of these.

TimingThe risk may occur before or after delivery.