The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Appealing Denial of Individual Claims for Homebirth Maternity Care

If you just want to send a simple letter, here's a great sample letter.

In an ideal system, there would be a lot of economic support for homebirth maternity care, because it costs less and has better outcomes.

In the system we currently have, insurance companies are in the business of making and keeping money.  Their first choice is for you to have a homebirth and pay for it all yourself.  Their second choice is for you to have a homebirth and for them to pay a minimal amount.  Their third choice is for you to have a homebirth and for them to pay a fair amount.  It should be their last choice for you to have a hospital birth, since that is about twice as expensive as a homebirth.  If you factor in the cost of the additional complications caused by planning a hospital birth (tripled c-section rate means tripled cost of hospital stay!), a properly reimbursed homebirth costs only about 25% of the average hospital birth.

Still, they will do everything they can to keep their money, and they know you're busy with a new baby.  Here are some ways to respond to denials of insurance claims for homebirth-related services.  This will help you to lobby better for yourself!

Many insurance companies deny claims for midwifery care beyond the standard procedure called "Global routine obstetrical care (code 59400)".  This code describes the four hours TOTAL of care typically provided by an OB for a hospital birth . . . about 2 hours total for prenatal care, 1 hour at the birth, and another hour of postpartum followup.

Anything beyond that those four hours of care is NOT included as part of total obstetrical care.
Obviously, this does not include home visits, and it obviously does not include baby care.

You can learn more about how midwives put together claims for the care they provide.  This includes the specific procedure codes that you may see on the paperwork you get from your insurance company.
 
 

Prenatal Care

Our maternity care system allows for only about two hours of total prenatal care for a normal pregnancy, i.e. about 20 minutes for the first appointment and about 10 minutes for each of 10 followup appointments.  This is all the time it takes to ask a few questions, measure a woman's blood pressure and her growing belly and to listen to the baby's heart.  This is the kind of care that only pays lip service to nutrition and maternal self care.  This is the kind of care that pretends that birth is a medical procedure, so the mother's emotional state doesn't affect the outcome.  This is the kind of care that doesn't pay any attention to the baby's position until it's past the ideal time for baby to turn head down.  This is the kind of care that doesn't pay any attention to whether the baby is rotating into the ideal position for birth, to avoid a posterior entry into the pelvis. This is the kind of care that results in a 30-40% cesarean rate, an infant mortality rate that is 47th in the world (2006?), low breastfeeding rates, postpartum depression, a rising autism rate and significant maternal dissatisfaction.

Yet this is the standard of care.

The better insurance companies will pay for longer appointments . . . 40 minutes for a routine appointment, and up to two hours if there are any complications that require significant discussion or time to help baby shift position.

You can make these arguments with your insurance company, and it is true that the squeaky wheel does get the oil.  So lobby for the kind of prenatal care you deserve!
 
 

Prenatal Home Visit

Dear Insurance Representative:
I am writing to explain the medical necessity for this service:
 

SERVICE DATE(s) PROCEDURE NUMBER UNITS OF SERVICE BILLED AMOUNT ALLOWED AMOUNT
<DATE> 99350 1 $XX $YY

The prenatal home visit around 36 or 37 weeks is standard of care for practitioners preparing to assist a woman birthing at home.  This is described in the premier texts for both CNMs (Nurse-Midwifery by Helen Varney, 2nd edition, p. 400 – “Preparation for the birth by the nurse-midwife includes: . . . A home visit during the thirty-sixth week of gestation . . .”) and for CPMs/LMs (Holistic Midwifery, Vol. 1, by Anne Frye, p. 793 – “Between the 34th and 37th week is  good time to plan to do a home visit.”).
This purpose of the prenatal home visit includes:
• Assessment of the home – birth room, bathroom, kitchen facilities, basic utilities
• Assessment of the birth bed for cleanliness and firmness
• Assessment of emergency preparations, including access for EMS
• Assessment of family dynamics, pets, siblings
• Discussion of placement for the birth tub and birth stool
• Inspection of the birth kit and other birthing supplies
• Continuation of screening for normalcy and appropriate preparedness
Although the prenatal home visit is considered standard of care for homebirth midwifery, it is not included as part of global routine obstetrical care.  It is medically necessary because it contributes to the improved outcomes for home-based midwifery care.
Please let me know if you would like me to provide copies of the relevant pages from these standard midwifery texts.  Thank you.
 

The Birth, coded as Global Routine Maternity Care or Global Routine Obstetrical Care

     59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

The word routine and the fact that these codes are for use only in situations where one physician provides all three components of the global service indicates the limits of these codes. Family
physicians can best understand these "global care codes" by understanding their three component parts: (1) antepartum care; (2) delivery; and (3) postpartum care.

According to CPT, routine antepartum care includes initial and subsequent history, physical exams, recording of weight, blood pressure, fetal heart tones, routine chemical (dipstick) urinalysis,
monthly visits up to 28 weeks gestation, biweekly visits between 28 and 36 weeks, and weekly visits until delivery. Under the CPT definition, a physician should not submit more than seven
maternity care visits in the first 28 weeks. Instead, the physician should code any other visits (even routine maternity care visits more frequent than once a month) separately. The same applies for
biweekly visits between 28 and 36 weeks.

The CPT manual states that delivery services include admission to the hospital, the admission history and physical exam, management of uncomplicated labor, vaginal delivery (with or without
episiotomy, with or without forceps), or cesarean delivery. Please note that the manual specifically refers to "uncomplicated" labor. If there are any complications, then one should use additional
codes. [Ed: "Management" of labor means management by phone while the nurses provide the hands-on maternal assessments, fetal monitoring, and nursing care.  It does not assume that the care provider is in face-to-face contact, which can be billed separately.]

The CPT manual states that postpartum care includes hospital and office visits following vaginal or cesarean section delivery. Of course, this includes not only the routine post-delivery hospital care
offered by a family physician, but also the postpartum visits in the office. However, this code does not include any laboratory services provided at the postpartum visit (e.g., PAP, blood work). It
is important to note that only one physician may bill for postpartum care. If both the family physician and a consultant who provided cesarean delivery see the patient postpartum, it must be
determined which physician will bill for the postpartum services.  [Ed: Note that this does not include home visits.]

Extra Time At The Birth - Mother Care

Dear Insurance Representative:
I am writing to appeal the partial or complete denial of the following claims, which were denied because "it is considered to be part of another service already performed and reimbursed."
 
 

SERVICE DATE(s)	PROCEDURE NUMBER	UNITS OF SERVICE	BILLED AMOUNT	ALLOWED AMOUNT
	99350	1
	A4550	1
	E1399	1
	59430	1
	99355	9

This letter explains the medical necessity of the prolonged face-to-face contact involved in the care of Client and her newborn around the time of her baby's birth on DOB, as well as the nature of the claims for 99350 and 59430. It should become clear that these services were not part of another service already performed and reimbursed.
It is the standard of care for the out-of-hospital midwife to attend the laboring woman throughout active labor in order to monitor the well-being of mother and baby.  This prolonged, face-to-face labor monitoring is not included in 59400, which describes labor management.  The labor management of 59400 is typically provided remotely by most birth attendants while the monitoring and hands-on care is provided by nursing staff.
It is also the standard of care for the out-of-hospital midwife to remain with the mother and newborn until they are both stable after the birth, typically about six hours postpartum.
Midwives or physicians practicing in the hospital customarily do not provide prolonged face-to-face services and postpartum care for routine cases because there is a staff of nurses to provide this care, which is not a part of 59400.  Midwives practicing in a birth center or a homebirth environment must remain with the laboring woman during active labor and must remain with the newly delivered mother because there is no institutional staff providing this care, so they are providing care beyond that described by 59400.
The State of California considers that care for the laboring woman, mother and newborn are so important that insurance companies are mandated to cover care during labor and birth and for 48 hours afterwards. (Ref: California Codes, Insurance Code, Section 10123.87)
I was the only healthcare professional who provided direct care for Client and her newborn during her labor and birth and the first 48 hours postpartum, other than my assistant, Christina Stone.  Around the time of birth, I was in attendance from 9/20/02, 1:40 pm when the client was in active labor, to 9/21/02, 1:42 am, when the postpartum mother and newborn were stable.  I was in attendance for a total of 12 hours.  Of this time, one hour was billed as a component of 59400, a second hour was billed as 99350, and a third hour was billed as 59430-25.  The remaining 9 hours were billed as 18 units of 99355 - 10 units occurred during the labor, and another 8 units occurred postpartum.

The <DOS> charges for A4550 and E1399 are typically part of the hospital charges - since Client was not hospitalized, these charges could not have been part of another service previously reimbursed. They certainly are not included in 59400.
I trust that this explains why my services were medically necessary and were not part of routine care described by 59400.  I'm sure you'll appreciate that I provided these services at a significantly lower cost than the cost of hospitalization for mother and baby.
 
 

Extra Time At The Birth - Baby Care

Obstetrical care does not include any baby care.

<DATE> 99350 1 $XX $YY

Re: Client, Subscriber ID#, Claim
 - Appeal of Denial of Charges for Unusual Services for
Newborn Care at a Homebirth

Dear Insurance Representative:
I am writing to appeal the partial or complete denial of the following claims, which were denied because "it is considered to be part of another service already performed and reimbursed."

SERVICE DATE(s) PROCEDURE NUMBER UNITS OF SERVICE BILLED AMOUNT ALLOWED AMOUNT
    <DATE> 99350 1 $XX $YY

This letter explains the medical necessity of the prolonged face-to-face contact involved in the care of Newborn around the time of birth on DOB. It should become clear that these services were not part of another service already performed and reimbursed.
It is the standard of care for the out-of-hospital midwife to remain with the newborn until the baby is stable after the birth, typically about six hours postpartum.  Midwives or physicians practicing in the hospital customarily do not provide prolonged face-to-face services and postpartum care for routine cases because there is a staff of nurses to provide this care.  However, midwives practicing in a birth center or a homebirth environment must remain with the newborn because there is no institutional staff providing this care.
The State of California considers that care for the laboring woman, mother and newborn are so important that insurance companies are mandated to cover care during labor and birth and for 48 hours afterwards. (Ref: California Codes, Insurance Code, Section 10123.87)
I was the only healthcare professional who provided direct care for Newborn for the first 48 hours postpartum. I was in attendance for a total of XX hours postpartum, until the newborn was stable.  Of this time, one hour was billed as 99344. The remaining XX hours were billed as YYY units of 99355.
I trust that this explains why my services were medically necessary and were not part of another service .  I'm sure you'll appreciate that I provided these services at a significantly lower cost than the cost of hospitalization.
 

Postpartum Mother Care

Dear Insurance Representative:
I am writing to appeal the partial or complete denial of the following claims, which were denied because "it is considered to be part of another service already performed and reimbursed."

SERVICE DATE(s) PROCEDURE NUMBER UNITS OF SERVICE BILLED AMOUNT ALLOWED AMOUNT
<DATE> 99350 1 $XX $YY

This letter explains the medical necessity of the home visits for MOTHER on DOS.
It is the standard of care for the homebirth midwife to continue providing in-home care for the birthing woman in the days immediately following birth.  Because the woman is not hospitalized, there are no other healthcare providers monitoring her well-being during this time.
Each of these in-home visits in the immediate postpartum is a comprehensive evaluation of the woman's current status and her interval history, including performing routine assessments of vitals and also providing breastfeeding assistance.  Each visit includes an evaluation of whether the woman is fine to remain at home or needs to be hospitalized.  This visit takes at least an hour, and there is additional travel time to and from the woman's home.  These services are not included in 59400.
The State of California considers that care for the laboring woman, mother and newborn are so important that insurance companies are mandated to cover care during labor and birth and for 48 hours afterwards. This includes in-home care as follows, " The visit shall include, at a minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments."(Ref: California Codes, Insurance Code, Section 10123.87)
I was the only healthcare professional who provided care for MOTHER in the first two weeks following the birth.  These home visits were in lieu of hospitalization, and I'm sure you'll appreciate that I provided these services at a significantly lower cost than the cost of hospitalization.
 
 

Postpartum Baby Care

Obstetrical care does not include any baby care.

As to medical necessity:

Re: Client, Subscriber ID#, Claim
 - Appeal of Denial of Charges for Unusual Services for
Newborn Care at a Homebirth

Dear Insurance Representative:

I am writing to appeal the partial or complete denial of the following claims, which were denied because "it is considered to be part of another service already performed and reimbursed."

SERVICE DATE(s) PROCEDURE NUMBER UNITS OF SERVICE BILLED AMOUNT ALLOWED AMOUNT
<DATE> 99350 1 $XX $YY

This letter explains the medical necessity of the home visit for BABY on DOS.
It is the standard of care for the out-of-hospital midwife to provide care for both the birthing woman and her newborn.  This is specifically described in our licensing law - California Codes Business and Professions Code, Sections 2505-2521, known and cited as the Licensed Midwifery Practice Act of 1993.
Midwives or physicians providing maternity care in the hospital customarily do not also provide newborn care.  However, midwives practicing in an out-of-hospital environment often also do provide newborn care.  This dovetails nicely with the provision of breastfeeding assistance, which  naturally involves both the new mother and the newborn.  Obviously, this newborn care and breastfeeding assistance include care beyond that described by 59400.
The State of California considers that care for the laboring woman, mother and newborn are so important that insurance companies are mandated to cover care during labor and birth and for 48 hours afterwards. This includes in-home care as follows, " The visit shall include, at a minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments." (Ref: California Codes, Insurance Code, Section 10123.87)
This details of newborn followup care are described in our practice guidelines:

Follow-up visits shall include assessment of the infant and procedures,
as indicated:

1) Status of the umbilical cord and clamp
2) Vital signs (temperature, pulse, respiratory rate, lungs)
3) Weight gain
4) Skin color
5) Feeding, hydration status, and elimination
6) Sleep/wake patterns
7) Bonding and family response to the baby's needs
8) Arranging for or drawing the required newborn screenings
9) Addressing the concerns of family

from http:

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I was the only healthcare professional who provided care for newborn Helena Blankenhaus in the first two weeks following the birth.  This home visit was in lieu of hospitalization, and I'm sure you'll appreciate that I provided these services at a significantly lower cost than the cost of hospitalization.
 
 

Transporting

Dear <Insurance Company Name> Representative:
I am writing to explain the sequence of events surrounding <Client Name>'s delivery of a baby <girl/boy> on <baby's birth date>.  <Client> planned to give birth at home but was transported to the hospital for the last <x hours> before giving birth.  She labored at home until she was well advanced in labor, when complications arose, at which time we transported to the hospital.  This transport was required by our licensure regulations and/or the local standard of care for homebirth midwifery.
The local standard of care for homebirth midwifery also requires that I accompany my clients to the hospital when there is a transfer of care.  Accordingly, I went with <Client> to the hospital, remained through the birth and was available for lactation consulting during the immediate postpartum.
<Client Name> received prenatal care in my practice from <start date> to <end date>; she had <How many?> prenatal visits, each lasting well over an hour.  She had a normal course of pregnancy, with prelabor starting on <date>.
We had a number of phone conversations of varying length over the next two days, as labor shifted from intermittent and irregular to more active.  I estimate that <Client Name> went into active labor around <time> on <date>; they called to inform me that the labor pattern had picked up, so I went to their home at <time>.
By <time>, the cervix was dilated to 5-6 cm, but labor became sporadic and irregular.  It seemed that the baby's head might be in a posterior position, but fetal landmarks weren't obvious, and I was having some difficulty with the assessment so around <time>, I called my assistant midwife, <assistant's name>, to come provide a consultation.
Over the course of the next eight hours, we worked on position changes to encourage the baby's head to assume a more favorable position and we tried a number of techniques to encourage a stronger labor pattern.
By <time>, the cervix had dilated completely, and <Client Name> began pushing.  Her pushing efforts were effective, but her contractions remained irregular.  There was some progress over the course of the next three hours, but the labor pattern was still unreliable, and we all agreed that it was time to transport to their local hospital for pitocin augmentation.  (I billed these first 12 hours as 99350 and 99355.)
We arrived at the Labor/Delivery ward at <Hospital> at <time> on <date>, and <Baby name> was born at <time> on <date>.  As is the standard of care for transports, I remained with <Client Name> and <Client's Partner's Name> through the remainder of her labor and birth, and then stayed for an additional two hours to provide lactation consulting services.  (I billed these five hours as 99357.)
I spent a total of <# hours> hours attending <Client Name>'s labor at home, her transport into the hospital, her labor and birth in the hospital and her immediate postpartum. This is significantly more time than average for a routine birth.
<Client Name> and <Client's Partner's Name> preferred to minimize their time in the hospital so went home the next day.  They asked if I would be available to provide postpartum care in their home during the time they would otherwise be in the hospital.  I agreed, as I normally provide in-home postpartum care for my clients, so they arranged to be discharged early from the hospital.
Indeed, I provided in-home postpartum and newborn care to <Client Name> and her newborn, <Baby name> on two occasions in the subsequent days, in lieu of the care they would have been receiving in the hospital.  I also saw them for an additional two visits in my office.  I'm sure you'll appreciate that the cost of my services for the postpartum care are significantly less than the cost of an additional day in the hospital, to which they are entitled by California law.
My  entire fee is due regardless of the transport: she had ten prenatal visits, each lasting well over an hour total of 21 hours in labor and lactation consulting in the immediate postpartum, four postpartum visits and three newborn visits..
Regarding the services of my assistant, <Assistant Name, Credentials>:
<Assistant name> was in attendance at <Client Name>  and <Client's Partner's Name>'s home from <time> on <date> to <time> on <date>.  In addition to her consultations, <Assistant name> assisted me by performing routine intermittent auscultation to assess the baby's well-being during the later stages of labor and pushing.  She left after we had completed preparations to transport into the hospital.
If you have any questions about <Client Name>'s prenatal or postpartum care, labor or transport into the hospital, please don't hesitate to contact me for additional information.  I can be reached by phone at <phone number> or by e-mail at <e-mail address>.
In addition, I am sure <Client Name> would be more than happy to discuss details in order to clarify matters relating to this claim.
 

Legal Recourse

Sample Letters