GENERAL INFORMATION 

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy 
(For evaluating the placenta or imaging the maternal pelvis without need for fetal assessment, use the pelvic MRI guideline, CAM 714)

INDICATIONS FETAL MRI
To better define or confirm any of the following:

• Known or suspected abnormality of the fetus after ultrasound has been performed¹
• Fetal surgery is planned
• Make a decision about therapy, delivery, or to advise the family about prognosis¹

Combination Studies
Pelvis and Fetal MRI

• When medical necessity has been met for Pelvis MRI (such as for suspected placenta accreta or percreta when ultrasound is indeterminate²) AND medical necessity has been met for Fetal MRI (such as suspected fetal abnormality after ultrasound has been performed), two separate authorizations are required: Pelvis MRI Pelvis MRI (CPT 72195, 72196, 72197) and Fetal MRI (CPT 74712, +74713).

Purpose
Fetal MRI¹
Fetal MRI should be performed only for a valid medical reason and only after careful consideration of sonographic findings or family history of an abnormality for which screening with MRI might be beneficial. Before 18 weeks gestational age, a fetal MRI may not provide additional diagnostic information due to the small size of the fetus and fetal movement when compared with sonography. The need for early diagnosis should be balanced against the advantages of improved resolution later in pregnancy, with the choice dependent on the anomalies to be assessed.
 

Contraindications and Preferred Studies

• Contraindications and reasons why a CT/CTA cannot be performed may include: impaired renal function, significant allergy to IV contrast, pregnancy (depending on trimester)
• Contraindications and reasons why an MRI/MRA cannot be performed may include: impaired renal function, claustrophobia, non-MRI compatible devices (such as non- compatible defibrillator or pacemaker), metallic fragments in a high-risk location, patient exceeds wight limit/dimensions of MRI machine.

References

1. Prayer D, Malinger G, De Catte L, De Keersmaecker B, Gonçalves L et al. ISUOG Practice Guidelines (updated): performance of fetal magnetic resonance imaging. Ultrasound in obstetrics gynecology: the official journal of the International. 2023; 61: 278-287. 10.1002/uog.26129.
2. Kilcoyne A, Shenoy-Bhangle A, Roberts D, Sisodia R, Gervais D. MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls. American Journal of Roentgenology. 2016; 208: 214 - 221. 10.2214/AJR.16.16281.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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