Clinical Guidelines and Medical Necessity

With constantly evolving medical treatment options, it is not unusual for NRECA staff to receive questions about why a supply, test or procedure isn’t covered under the NRECA Medical Plan. The determination of whether a service, supply, test or procedure is medically necessary and covered under the plan is based on evidence-based medicine, using generally accepted standards of good practice within the medical community. To assist in the determination of whether a service, supply, test or procedure is medically necessary, NRECA does consult a number of industry resources, including Hayes Technology Assessment, Aetna Clinical Policy Bulletins, UnitedHealthcare Medical Policies and Coverage Determination Guidelines and/or NRECA Plan Clinical Policy Guidelines.

For example, digital breast tomosynthesis, commonly called 3D mammography, is currently in the news. NRECA considers annual mammograms a preventive screening and medically necessary for early detection of breast cancer in women 40 and older. However, NRECA does not currently cover 3D mammography because there is insufficient evidence to conclude it is effective for the screening or diagnosis of breast cancer. Clinical trials and studies are still underway that compare the effectiveness for outcomes of 3D mammograms. Until the clinical effectiveness is proven, 3D mammography is not considered medically necessary for the screening and diagnosis of breast cancer.

As with all coverage policies, NRECA will continue to monitor the latest studies, and, if evidence proves 3D mammography to be an effective preventive screening, the guidelines and NRECA coverage policy will be updated to support its use. For now, participants who wish to use 3D mammography may do so but must pay the additional cost for the screening.

If you have questions, call the Member Contact Center, Monday – Friday, 7 am to 7 pm CT, at 866.673.2299, or email contactcenter@nreca.coop.