CurrentmhnPolicy CP.MP.136

Clinical Policy: Home Births

Defines medical necessity criteria under which planned home births are considered medically necessary by Centene-affiliated health plans, including provider qualifications, patient selection criteria, and emergency planning requirements. Also provides background, references, and coding guidance (informational).

Policy Summary

Payermhn

PolicyClinical Policy: Home Births

Policy CodePolicy CP.MP.136

Change TypeRevised (criteria and minor wording updates)

Effective DateN/A

Next Review DateN/A

Key ActionDocument that the attending midwife or physician meets the specified certification/education/licensure standards and practices within an integrated and regulated health system (as applicable).

POLICY UPDATE CHANGES

Added requirement that midwives practice within an integrated and regulated health system and clarified singleton pregnancy estimated to be appropriate for gestational age.

Edited language regarding emergency facility access for physician-overseen care to match midwife-overseen care and clarified NRP certification requirement.

9Core eligibility criteria items

4CPT codes listed (informational)

15Transport time threshold (min)

Coverage Summary

Coverage summary: Planned Home Births (CP.MP.136) are covered with criteria when all specified medical necessity conditions are met. Key thresholds: emergency transport must be documented as achievable within 15 minutes from onset of an emergency; spontaneous labor eligibility is for pregnancies lasting between 37 0/7 and 41 6/7 weeks; outpatient induction eligibility is for pregnancies between 39 0/7 and 41 6/7 weeks.

Display thresholds[] as key/value pairs: Emergency transport time, Spontaneous labor gestational age, Outpatient induction gestational age. Use 'Transport time threshold' stat color (amber) for emphasis on transport time entry.

Emergency transport time<= 15 minutes from onset of an emergency condition to nearest appropriate hospital

Spontaneous labor gestational age>= 37 0/7 weeks and <= 41 6/7 weeks

Outpatient induction gestational age>= 39 0/7 weeks and <= 41 6/7 weeks

Medically Necessary Criteria for Planned Home Birth

Medically Necessary Criteria for Home Birth

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

Birth overseen by a participating and credentialed provider who meets ONE of:

If managed by a midwife
- Midwife must be certified by the American Midwifery Certification Board (or 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, and practicing within an integrated and regulated health system
- Written plan for emergency care includes documentation that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from the onset of an emergency condition<= 15 minutes
If managed by a physician
- Physician practices obstetrics within an integrated and regulated health system
- If physician is not an obstetrician or a family practice physician who has completed an obstetrics fellowship, there is documented proof of back-up supervision and coverage by a board certified or active candidate for certification by the American Board of Obstetrics and Gynecology
- Emergency care is planned at a facility where the supervising obstetrician has admitting privileges
- Written plan for emergency care includes documentation that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from the onset of an emergency condition<= 15 minutes

Care provider staffing

Two care providers are planned to be present at the birth
One provider has primary responsibility for the birthing individual
One provider has primary responsibility for the infant, is certified in the Neonatal Resuscitation Program (NRP), and has equipment to perform a full resuscitation of the infant per NRP principles

No preexisting medical condition(s) that increase pregnancy risk

No prior caesarean delivery

Absence of significant disease during pregnancy

Singleton pregnancy estimated to be appropriate for gestational age

Fetal presentation is cephalic

Gestational age / labor status

Spontaneous labor in a pregnancy that has lasted at least 37 0/7 weeks but no more than 41 6/7 weeks>= 37 0/7 and <= 41 6/7 weeks
Induced as an outpatient in a pregnancy that has lasted at least 39 0/7 weeks but no more than 41 6/7 weeks>= 39 0/7 and <= 41 6/7 weeks

There is a preexisting arrangement for emergency transportation to a nearby hospital if needed

Provider Actions & Documentation Requirements

Documentation Required

Provider credentialing and certification documentation

Document that the attending midwife or physician meets the specified certification, education, and licensure standards and that the provider practices within an integrated and regulated health system as applicable.

If midwife: certification by the American Midwifery Certification Board (or predecessor) OR education/licensure meeting International Confederation of Midwives Global Standards, and practicing within an integrated and regulated health system.
If physician: practices obstetrics within an integrated and regulated health system; if not an OB or family practice physician with OB fellowship, document back-up supervision/coverage by a board-certified or active candidate for certification by the American Board of Obstetrics and Gynecology.

Documentation Required

Emergency transport and facility arrangement

Maintain and document a written emergency care plan showing timely access to hospital care and required facility arrangements for physician oversight where applicable.

Written plan must document that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition.
For physician oversight, document that emergency care is planned at a facility where the supervising obstetrician has admitting privileges.

Documentation Required

Staffing and neonatal resuscitation documentation

Document planned staffing for the birth and neonatal resuscitation capability.

Plan for two care providers to be present at the birth.
Identify one provider with primary responsibility for the birthing individual and one provider with primary responsibility for the infant.
Document that the infant-responsible provider is certified in the Neonatal Resuscitation Program (NRP) and has equipment to perform a full resuscitation per NRP principles.

Denial Risk

Coverage denial risk for high-risk conditions

Claims may be denied as not medically necessary if the home birth eligibility criteria are not met.

Prior caesarean delivery
Multiple gestation
Non-cephalic (non-vertex) fetal presentation
Preexisting medical conditions that increase pregnancy risk
Significant disease during pregnancy
Gestational age outside specified ranges (less than 37 0/7 weeks or greater than 41 6/7 weeks for spontaneous labor; for outpatient induction, less than 39 0/7 weeks or greater than 41 6/7 weeks)

Coding (informational)

Referenced CPT codes (informational)CPT

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)

HCPCS codes referencedHCPCS

N/A	No HCPCS codes specified

Note: The listed CPT codes are provided for informational purposes only and are not exhaustive billing guidance. Providers should reference current coding resources and the provider_actions documentation callouts (credentialing, emergency transport plan, staffing/NRP documentation) to support coverage determinations and claims.

Background & Evidence

Background: Planned home birth is an elective alternative to hospital or birthing center delivery and requires appropriate risk screening and a system that allows collaboration, referral, and transfer to hospital care. Professional societies (ACOG and AAP) caution that planned home birth is associated with an increased neonatal risk (about a twofold to threefold higher risk of neonatal death compared with planned hospital birth) and recommend that birthing individuals be informed of these risks and that emergency access and timely transport to nearby hospitals be ensured.

Render evidence[] as a key/value pair: label 'Neonatal mortality risk' with value from evidence[0].

Neonatal mortality riskPlanned home birth associated with twofold to threefold increased risk of neonatal death vs planned hospital birth (per ACOG/AAP statements and cited observational studies)

Definitions / Glossary:

• NRP: Neonatal Resuscitation Program.

• Integrated and regulated health system: A system in which the provider practices within a regulated framework allowing collaboration, referral, and transfer to hospital care as described in the policy.

Revision History

09/20material_revision

Added requirement that midwives practice 'within an integrated and regulated health system'; added that singleton pregnancy is 'estimated to be appropriate for gestational age'; added criteria that two caregivers are planned to attend the birth and that the infant-responsible provider is trained in the Neonatal Resuscitation Program (NRP); revised gestational age language specifying spontaneous labor at least 37 0/7 weeks and clarified no more than 41 6/7 weeks; added separate criteria for outpatient induction (39 0/7 to 41 6/7 weeks).

01/22non_material_revision

Edited language regarding emergency facility access for physician-overseen care to match midwife-overseen care and reformatted staffing criteria to clarify that at least one provider is certified in the Neonatal Resuscitation Program; references reviewed and updated.

01/23non_material_revision

Annual review with minor rewording and no clinical significance; removal of criteria II and ICD-10 codes; references reviewed and updated.

01/24non_material_revision

Annual review with minor rewording in Criteria and Background sections with no impact on policy criteria; references reviewed and updated.

01/25non_material_revisionLatest

Annual review; references reviewed and updated; external specialist reviewed. (Most recent annual revision log entry.)