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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).For services furnished on or after July 1, 2002, Medicare will cover the use of home INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin. The monitor and the home testing must be prescribed by a physician and the following patient requirements must be met: - Must have been anticoagulated for at least 3 months prior to use of the home INR device; - Must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and - Self testing with the device is limited to a frequency of once per week. You can find this information in National Coverage Determination (NCD) for Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management (190.11).60.1 Coverage RequirementsFor services furnished on or after March 19, 2008, the Centers for Medicare & Medicaid Services revised its national coverage determination (NCD) on PT/INR Monitoring for Home Anticoagulation Management as follows: Medicare will cover the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following requirements must be met: 1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and, 2. The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstratedthe correct use of the device prior to its use in the home; and, 3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and, 4. Self-testing with the device should not occur more frequently than once a week. 60.4 Healthcare Common Procedure Coding System for IntermediariesG0249: Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meetsMedicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.60.6 -Carrier Claims Requirements Note this test is not covered as durable medical equipment. Therefore, claims submitted to DMERCs will not be paid. It is covered under the physician fee schedule. Also note that the cost of the device and supplies is included in the payment for G0249 and therefore not separately billed to Medicare. G0249 continues to include materialsfor 4 tests. Additionally, G0250 continues to mean per 4 tests and should be billed no more frequently than once every 4 weeks.You can find this information in Medicare Claims Processing Manual Chapter 32 -Billing Requirements for Special Services.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules