Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for water birth, delayed cord clamping longer than two minutes, and in-home postnatal care and checkup.Water birth has been advocated as a non-pharmacologic technique. However, according to a review by Cluett and colleagues, evidence of the efficacy of water birth is limited since few randomized trials have been performed and most had a small number of subjects, wide variations in patient populations or study design, and methodological flaws. Moreover, a committee opinion by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) concluded, The practice of water immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. Based on the above, a water birth is not medically necessary for the patients pregnancy.The ACOG committee opinion recommends delaying umbilical cord clamping after birth in vigorous term infants. The AAP and most other clinical practice guidelines also endorse this approach. Although the optimal amount of time before cord clamping has not been studied extensively, ACOGs recommendation is to delay cord clamping for at least 30 to 60 seconds; others have suggested a two to five-minute delay, or longer if the mother requests. According to a meta-analysis by McDonald and colleagues, compared with early cord clamping, late cord clamping resulted in higher neonatal hemoglobin levels at 24 to 48 hours after birth, but not in subsequent assessments, and a lower proportion of infants with iron deficiency at three to six months of age. However, late cord clamping also resulted in a 40 percent increase in newborns needing phototherapy for jaundice. In addition to exacerbation of jaundice, delayed cord clamping may result in increased blood viscosity owing to greater red cell mass, delayed respiratory support, and hypothermia. Based on the above, delayed cord clamping longer than two minutes is not medically necessary for the patients pregnancy.In a review by Yonemoto and colleagues, increased frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilization. However, the authors conclude, The certainty of evidence was found to be low and findings were not consistent among studies and comparisons. In this case, the medical literature does not indicate the necessity of the requested in-home postnatal care and checkups. Therefore, the in-home postnatal care and checkup are not medically necessary for the patients pregnancy.Therefore, the requested water birth, delayed cord clamping longer than two minutes, and in-home postnatal care and checkup are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.