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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 screening tests are excluded from coverage. The only exceptions are for the following 
services: 
 
1. screening mammography,  
2. colorectal cancer screening tests, 
3. screening pelvic exams,  
4. prostate cancer screening tests,  
5. glaucoma screening exams,  
6. ultrasound screening for abdominal aortic aneurysms (AAA),  
7. cardiovascular disease screening tests,  
8. diabetes screening tests, and 
9. screening electrocardiograms, and 
10. certain other testing recommended by the United States Preventive Services Task Force and approved by 
the Centers for Medicare and Medicaid Service. 
 
You can find this rule at 42 CFR Section 411.15(a)(1) and 42 CFR Section 410.64. 
 
The rules say that indications for prothrombin time (PT) test are: 
 
1. A PT may be used to assess patients taking warfarin. The prothrombin time is generally not useful in monitoring patients receiving heparin who are not taking warfarin. 2. A PT may be used to assess patients with signs or symptoms of abnormal bleeding or thrombosis. For 
example: swollen extremity with or without prior trauma; unexplained bruising; abnormal bleeding, 
hemorrhage or hematoma; petechiae or other signs of thrombocytopenia that could be due to 
disseminated intravascular coagulation. 
3. A PT may be useful in evaluating patients who have a history of a condition known to be associated 
with the risk of bleeding or thrombosis that is related to the extrinsic coagulation pathway. Such 
abnormalities may be genetic or acquired. For example: dysfibrinogenemia; afibrinogenemia 
(complete); acute or chronic liver dysfunction or failure, including Wilson's disease and 
Hemochromatosis; disseminated intravascular coagulation (DIC); congenital and acquired deficiencies 
of factors II, V, VII, X; vitamin K deficiency; lupus erythematosus; hypercoagulable state; 
paraproteinemia; lymphoma; amyloidosis; acute and chronic leukemias; plasma cell dyscrasia; HIV 
infection; malignant neoplasms; hemorrhagic fever; salicylate poisoning; obstructive jaundice; intestinal 
fistula; malabsorption syndrome; colitis; chronic diarrhea; presence of peripheral venous or arterial 
thrombosis or pulmonary emboli or myocardial infarction; patients with bleeding or clotting tendencies; 
organ transplantation; presence of circulating coagulation inhibitors. 
4. A PT may be used to assess the risk of hemorrhage or thrombosis in patients who are going to have a 
medical intervention known to be associated with increased risk of bleeding or thrombosis. For 
example: evaluation prior to invasive procedures or operations of patients with personal history of 
bleeding or a condition associated with coagulopathy prior to the use of thrombolytic medication. 
 
Testing prior to any medical intervention associated with a risk of bleeding and thrombosis (other than 
thrombolytic therapy) will generally be considered medically necessary only where there are signs or 
symptoms of a bleeding or thrombotic abnormality or a personal history of bleeding, thrombosis or a condition 
associated with a coagulopathy. Hospital/clinic-specific policies, protocols, etc., in and of themselves, cannot 
alone justify coverage. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare National Coverage Determination for Prothrombin Time, 190.17  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.