Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pregnancy. 
Treatment:  Home Birth. 

The insurer denied the Home Birth.  The determination is upheld.

The patient is a female under consideration of a determination of medical necessity for home birth for pregnancy complicated by advanced maternal age.  The patient was deemed a high risk pregnancy due to advanced maternal age.  In this case, the patient is a gravida (G) 4 para (P) 3 with three prior vaginal deliveries.  The patient had no previous cesarean deliveries.  The patient has a height of 5 feet 11 inches and weight of 145 pounds for a body mass index of 20.2 kilograms per meters squared (kg/m2).  The patient underwent an early anatomy scan at 16 weeks gestation with a routine anatomy scan at 21 weeks gestation and a growth scan at 20 weeks gestation that were noted to be normal.  The patient did undergo noninvasive prenatal testing, which deemed her low risk for common aneuploidy.  During the pregnancy, the patient had normal blood pressures.  Her prenatal labs were normal.  The patient had a 1 hour Glucola 1:15.  The patient was seen by telephone health visits during the pandemic and was planning to transfer her prenatal care from New York City to Pennsylvania (Rising Moon Birth Services) given the pandemic outbreak of COVID-19 in New York.  Her prior pregnancy history included a delivery in 2009 at 40 weeks gestation resulting in a female 7 pounds.  This delivery was in a birth center.  Her second pregnancy was in 2011 at 41-1/2 weeks gestation resulting in a 7 pound female infant delivered by spontaneous vaginal delivery.  This delivery took place at home.  Her third pregnancy was delivered at 41 weeks gestation with a birth weight of 7 pounds with a female infant by vaginal birth at a birth center.  This would be the patient's fourth delivery with the current pregnancy under consideration.  The patient was seen during pregnancy for formal genetics consultation due to advanced maternal age.  The patient's genetic history noted that she had one biochemical pregnancy as well as one termination of pregnancy due to a prenatal diagnosis of trisomy 18 by chorionic villous sampling.  The patient underwent noninvasive screening in this pregnancy for evaluation.  Her final result was screen-negative with the fetal fraction of 1516% at 17 weeks gestation by Vistara.  The patient was also a risk by panorama with a fetal fraction of 7.5% at 11 weeks gestation in this pregnancy.  The patient delivered a male infant.  She had been living in New York and left New York due to COVID-19 and concerns for risk in hospitals for COVID-19. She had also left New York and established care for a home birth in Pennsylvania.  The patient's care was ultimately transferred to Rising Moon Birth Service that has provision of services by professional midwives.  These type of midwives are not licensed in the state of PA where the services were provided.  The Emergency care plan for the Rising Moon Birth Services also stated that they have no formal arrangement with doctors or hospitals for emergency care.  The patient had requested coverage in PA due to the pandemic in New York City and felt delivery in New York was not possible.  Thus, the patient was requesting a home birth as a service not under her plan.  In this case, the plan denied the request for coverage, as the patient was a high risk pregnancy given the maternal age of 48 years at delivery.  The plan stated that a home birth was not medically necessary for a high risk pregnancy as presented by this case. 

The health plan's determination of medical necessity is upheld, in whole. 

In this case home birth is not medically necessary.  There is never a medical need for a home birth when alternatives to care that provide additional safety and intervention capability are present such as a birthing center or hospital.  In the United States, approximately 35,000 births (0.9%) per year occur in the home.  Approximately one fourth of these births are unplanned or unattended.  Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.  Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.  These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals.  In this case, the home birth was attended by a service that had no backup or transport plan in place.  

The requested service/treatment of Home Birth would not be medically necessary for this patient as reviewed in concert with the medical records and plans of care as outlined in the Rising Moon documentation.  In this case, the patient was a high risk pregnancy with a prior history of Trisomy 18 pregnancy and the current pregnancy was noted to have been complicated by advanced maternal age (> 35 years at delivery - 48 years of age in this case).  Thus, the requested service/treatment of home birth would not be considered medically necessary.