Anthem Blue Cross ConnecticutCommercial Clinical Policy

CG-DME-30 Prothrombin Time Self-Monitoring Devices Form

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Home Prothrombin Time Self-Monitoring

Indications

(72275) Does the patient require long-term anticoagulation with warfarin for more than one year? 
(72276) Does the patient require at least weekly determinations of INR values? 
(72277) Has the patient's treating physician prescribed the self-monitoring device and home testing? 

Contraindications

(72278) Is the home prothrombin time self-monitoring not prescribed by a treating physician or required less than weekly INR determinations, or is it not needed for long-term anticoagulation with warfarin lasting more than one year? 
Effective Date

01/03/2024

Last Reviewed

11/09/2023

Original Document

  Reference



This document addresses the clinical indications for use of battery-operated prothrombin time self-monitoring devices, also referred to as International Normalized Ratio (INR) devices, used by individuals in the home to monitor blood-clotting rates.

Clinical Indications

Medically Necessary:

Home prothrombin time self-monitoring using an INR device is considered medically necessary for an individual who meets all of the following criteria:

  1. Requires long term (greater than one year) anticoagulation with warfarin; and
  2. Requires at least weekly determinations of INR values; and
  3. The treating physician prescribes the self-monitoring device and home testing.

Not Medically Necessary: 

Home prothrombin time self-monitoring is considered not medically necessary for an individual who does not meet the above criteria.

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