Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesRadiology/Diagnostic ImagingTexas Children's Maternal MRI Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentTexas Children's Health PlanPolicy 11220

    Maternal Magnetic Resonance Imaging (MRI)

    Customize your policy alerts

    Sign up for texaschildrenshealthplan Policy 11220 alerts

    Get alerted when Policy 11220 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Coverage and prior authorization requirements for fetal, placental, and maternal pelvic MRI for pregnant Texas Children's Health Plan members.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyMaternal Magnetic Resonance Imaging (MRI)
    Policy CodePolicy 11220
    Change TypeNo material change
    Effective DateJun 27, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization and submit medical-necessity documentation plus a treating physician clinic note dated within 30 days of the request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Covered MRI procedure codes
    RequiredPrior authorization
    30 daysClinic note age limit
    3Fetal MRI indications
    Limited use

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Gadolinium contrast

    Fetal MRI Coverage Criteria

    Fetal MRI Clinical Indications

    Fetal MRI is indicated when ANY of the following clinical situations is present:

    ANY of the following

    • An abnormality on ultrasound is not clearly defined and more information is sought to make a decision about therapy or delivery, or to advise the family about prognosis (for example, a potential anomaly in the setting of maternal obesity, oligohydramnios, or advanced gestational age).
    • An abnormality is identified with ultrasonography and the treating physician requires MRI-specific information to make decisions about care.
    • The fetus is significantly at risk for an abnormality that could affect prognosis, even if no finding is discovered with ultrasound (for example, neurologic ischemia after laser ablation of placental anastomoses in Twin-Twin Transfusion Syndrome).

    Fetal MRI Safety and Appropriateness Requirements

    Fetal MRI is covered when ALL of the following safety and appropriateness requirements are met:

    ALL of the following

    • Screening for ferromagnetic devices or implants in the mother is negative.
    • Gestational age is appropriate. There are no specific FDA guidelines regarding gestational age; based on available data regarding risk of teratogenicity, the American College of Radiology has concluded that no special consideration is recommended for the first trimester compared with any other trimester of pregnancy. No current evidence shows that fetal MRI is harmful to either the mother or fetus.
    • The fetal MRI has an appropriate clinical indication.
    • Gadolinium contrast is limited to situations in which the benefits clearly outweigh the possible risks. It may be used in a pregnant woman only when it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.

    Covered Clinical Indications

    Clarification of an Incompletely Defined Ultrasound Abnormality

    Covered when the following criterion is met:

    Clarification of an incompletely defined ultrasound abnormality: An abnormality on ultrasound is not clearly defined and more information is sought in order to make a decision about therapy, delivery, or to advise a family about prognosis

    Examples include a potential anomaly in the setting of maternal obesity, oligohydramnios, or advanced gestational age

    MRI-Specific Evaluation of an Ultrasound-Identified Abnormality

    Covered when the following criterion is met:

    MRI-specific evaluation of an ultrasound-identified abnormality: An abnormality is identified with ultrasonography and the treating physician desires MRI-specific information in order to make decisions about care

    High-Risk Fetus Despite No Ultrasound Finding

    Coding and Documentation for Billing

    Covered MRI procedure codesCPTCovered
    74712Magnetic resonance imaging (MRI) of the fetus, placenta, and maternal pelvic imaging
    74713Magnetic resonance imaging (MRI) of the fetus, placenta, and maternal pelvic imaging
    Treating Physician Clinic Note
    Required timingThe treating physician clinic note must be dated within 30 days of the prior authorization request.

    Prior Authorization and Review Actions

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for covered MRI of the fetus, placenta, and maternal pelvis, including procedure codes 74712 and 74713. Submit the required request materials to TCHP before services are rendered.

    • Affected imaging: fetal, placental, and maternal pelvic MRI
    • Procedure codes: 74712 and 74713
    Documentation Required

    Current Clinical Note Required

    The current treating physician must submit a clinic visit note dated within 30 days of the request explaining the need for fetal MRI. The note must accompany the prior authorization form.

    • Note must be dated within 30 days of the request
    • Note must explain the medical need for fetal MRI

    Clinical Background

    Fetal MRI is used as an adjunct to ultrasound when additional anatomic or diagnostic information is needed to guide decisions about therapy, delivery planning, prognosis, or ongoing care. It may also be considered when the fetus is at significant risk for an abnormality that could affect prognosis, even when ultrasound has not identified a finding.

    Abbreviations and Organizations

    Definition
    FDAFood and Drug Administration
    Definition
    ACRAmerican College of Radiology

    Prior Authorization Scope

    Prior Authorization

    Authorize each requested MRI service

    Prior authorization is required for each requested covered service involving MRI of the fetus, placenta, or maternal pelvis.

    Gadolinium Contrast Rules

    Billing Rule

    Limit gadolinium contrast during pregnancy

    During pregnancy, limit gadolinium contrast use to situations in which the benefits clearly outweigh the possible risks. Use it only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyMaternal Magnetic Resonance Imaging (MRI)
    Policy CodePolicy 11220
    Change TypeNo material change
    Effective DateJun 27, 2023
    Next Review DateN/A
    Key ActionObtain prior authorization and submit medical-necessity documentation plus a treating physician clinic note dated within 30 days of the request.
    SourceLink
    On This Page
    Fetal MRI Coverage CriteriaCovered Clinical IndicationsCoding and Documentation for BillingPrior Authorization and Review ActionsClinical BackgroundAbbreviations and OrganizationsPrior Authorization ScopeGadolinium Contrast Rules

    Covered when the following criterion is met:

    High-risk fetus despite no ultrasound finding: A fetus is significantly at risk for an abnormality that will affect prognosis even if no finding is discovered with ultrasound

    Example: neurologic ischemia after laser ablation of placental anastomoses in Twin-Twin Transfusion Syndrome

  1. Submit the note with the prior authorization form
    2. Documentation Required

    Medical-Necessity Documentation

    Documentation supporting the medical necessity of the requested imaging must accompany the prior authorization request. Include the clinical information supporting the indication for fetal MRI and the requested service.

    • Provide medical-necessity documentation with the prior authorization request
    • Documentation should support the requested imaging as an eligible service
    Note

    Submit Through Utilization Management

    Utilization Management receives fetal MRI prior authorization requests through fax, mail, or electronic submission and processes them during normal business hours.

    • Submission channels: fax, mail, or electronic submission
    • Requests are received and processed by the Utilization Management Department
    Denial Risk

    Requests Missing Guideline Criteria

    Requests that do not meet the guideline criteria are referred to a TCHP Medical Director or physician reviewer. The Denial Policy will be followed.

    • Noncompliant requests undergo physician-level review
    • A denial may result under the applicable Denial Policy
    Denial Risk

    Insufficient Medical Necessity or Safety Support

    Approval depends on medical necessity and compliance with the guideline’s clinical and safety requirements. Requests may face denial or additional review when the indication or supporting documentation is insufficient, maternal ferromagnetic-device screening is not negative, or gadolinium use is not justified by benefits that clearly outweigh possible risks.

    • Fetal MRI indications include an unclear ultrasound abnormality requiring additional information, an ultrasound-identified abnormality requiring MR-specific information, or significant fetal risk for an abnormality affecting prognosis even without an ultrasound finding
    • Confirm negative maternal screening for ferromagnetic devices or implants
    • Use gadolinium during pregnancy only when it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome
    • Preauthorization is not a guarantee of benefits or eligibility; benefit limitations and exclusions still apply