59409
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
14.37
Facility
$721.79
Non-Facility
$721.79
Documentation Required
- Proof of midwife certification by the American Midwifery Certification Board or documentation that midwife education/licensure meets International Confederation of Midwives Global Standards.
- Evidence that the midwife (or managing physician) practices within an integrated and regulated health system.
- A written emergency care plan documenting that emergency transportation to the nearest appropriate hospital is achievable within 15 minutes from onset of an emergency condition.
- Documented proof of backup supervision and coverage by a board-certified or active ABOG candidate when the delivering physician is not an obstetrician or family physician with an obstetrics fellowship.
Key Coverage Criteria
- Planned home birth is considered when coverage is mandated by law or by the member/enrollee’s benefit language.
- Home birth is medically necessary when overseen by a participating, credentialed Plan provider who meets the policy's specified provider criteria (e.g., midwife meeting all required conditions).
- Home birth attended by a midwife who is certified by the American Midwifery Certification Board (or predecessor) or whose education/licensure meets International Confederation of Midwives Global Standards and who practices within an integrated, regulated health system.
- Planned home birth with a written emergency care plan that documents emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition.
- Home birth services managed by a physician who practices obstetrics within an integrated, regulated health system.
- If the delivering physician is not an obstetrician or a family practice physician who completed an obstetrics fellowship, there must be documented backup supervision and coverage by a physician who is board certified or an active candidate for certification by the American Board of Obstetrics and Gynecology (ABOG).
1 Active Policy
AMBETTER-CP.MP.136 — Home Births
Related Codes
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