Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth. 
Treatment: Maternity and Newborn Care. 

The insurer denied routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care with an out-of-network provider for medical necessity. 
The denial is upheld in whole.

The patient is a gravida (G)3 para (P)2. The patient has no genetic history and no significant history. The prior pregnancy history is noted for a hospital live birth at 7 pounds (lbs) 9 ounces (oz) at 39 weeks gestation. She then also had a delivery resulting in a 7 lbs 4 oz infant. She has no allergies. She declined Rhogam at 28 weeks.
At issue is the medical necessity of routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care with an out-of-network provider.

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

The requested health service/treatment of routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care with an out-of-network provider is not medically necessary for this patient.
The American College of Obstetrics and Gynecology states the following, "Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it 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. Specifically, they 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. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes." Given that birth outcomes are generally superior in hospitals or birthing centers, home birth cannot be recommended as medically necessary. The patient has a right to select this service as an option, but there is no high-quality evidence to support home births, as there are no large randomized clinical trials to support the plan of a home birth.
Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery in a study from 2010. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates. These rates of neonatal mortality were tripled in these cases.
The obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care with an out of network provider is not medically necessary.