Diagnosis: Pregnancy/ Childbirth.
Treatment: Home birth with an out-of-network provider.

The insurer denied coverage for the home birth with an out-of-network provider.

The denial is overturned.

This is a female with no significant medical history requesting coverage for a home birth with an out-of-network provider. The pregnancy was reported as uncomplicated. The patient has been evaluated by a licensed provider and not found to have any risk or complication. The insurer had no in-network provider able to render the requested service.

The patient meets all the insurer's policy requirements for a home birth with the out-of-network provider. Usually referral to an out of network provider is medically necessary if the services are not available from an in-network provider. The Plan stated that there was no in network provider available and since this patient meets the Insurer's criteria for a home birth, the requested services were medically necessary and eligible for coverage.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. The home birth with the out-of-network provider is considered medically necessary.

The carrier's denial of coverage for the home birth with an out-of-network provider is overturned. The medical necessity is substantiated.