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
To better define or confirm a known or suspected abnormality of the fetus after ultrasound has been performed¹ or when fetal surgery is planned, and/or to make a decision about therapy, delivery or to advise the family about prognosis^2,3

Safety guidelines and possible contraindications
There are no documented fetal indications for the use of MRI contrast, but there may be rare instances where contrast is considered potentially helpful in assessing the pregnant patient’s anatomy or pathology. However, its use is controversial with uncertainty surrounding the risk of possible fetal effects because gadolinium is water-soluble and can cross the placenta. The decision to administer contrast must be made on a case-by-case basis by the attending radiologist who will discuss with the patient and assess the risk-benefit ratio for that patient. The decision to administer a gadolinium-based MR contrast agent to pregnant patients should be accompanied by a well-documented and thoughtful risk-benefit analysis.⁴

Rationale
MRI not only contributes to diagnosis, but also serves as an important guide to treatment, delivery planning, and counseling. However, sonography is the screening modality of choice in the fetus. The advantage of MRI over ultrasound is its ability to image deep soft tissue structures without relying on the skill of the operator or limitations of patient body habitus.

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.

According to the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, the preponderance of animal studies demonstrates no risk of teratogenesis to the fetus, and tissue heating from MRI scanners is negligible near the uterus. Furthermore, in human studies of patients undergoing MRI, there have been no acoustic injuries to the fetus during prenatal MRI. Currently there is no documentation of deleterious effects of MRI at 1.5T and 3T on the developing fetus.²

References

1. Prayer D, Malinger G, Brugger PC, et al. ISUOG Practice Guidelines: performance of fetal magnetic resonance imaging. Ultrasound Obstet Gynecol. May 2017;49(5):671-680. doi:10.1002/uog.17412
2. ACR-SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). American College of Radiology (ACR), Society for Pediatric Radiology (SPR). Updated 2020. Accessed November 13, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-Fetal.pdf
3. Stout JN, Bedoya MA, Grant PE, Estroff JA. Fetal Neuroimaging Updates. Magn Reson Imaging Clin N Am. Nov 2021;29(4):557-581. doi:10.1016/j.mric.2021.06.007
4. Committee Opinion Number 723: Guidelines for diagnostic imaging during pregnancy and lactation. American College of Obstetricians and Gynecologists (ACOG). Updated October 2017. Accessed November 13, 2022. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Guidelines-for-Diagnostic-Imaging-During-Pregnancy-and-Lactat

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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