Anthem Blue Cross Connecticut CG-DME-30 Prothrombin Time Self-Monitoring Devices Form
This procedure is not covered
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:
- Requires long term (greater than one year) anticoagulation with warfarin; and
- Requires at least weekly determinations of INR values; and
- 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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