Appeal type: unknown
Decision: unknown

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 the indications for partial thromboplastin time (PTT) are: 
 
1. The PTT is most commonly used to quantitate the effect of therapeutic unfractionated heparin and to 
regulate its dosing. Except during transitions between heparin and warfarin therapy, in general both the PTT 
and PT are not necessary together to assess the effect of anticoagulation therapy. PT and PTT must be justified 
separately. 
 
2. A PTT may be used to assess patients with signs or symptoms of hemorrhage or thrombosis. For example: 
abnormal bleeding, hemorrhage or hematoma petechiae or other signs of thrombocytopenia that could be due to 
disseminated intravascular coagulation; swollen extremity with or without prior trauma. 
 
3. A PTT may be useful in evaluating patients who have a history of a condition known to be associated with 
the risk of hemorrhage or thrombosis that is related to the intrinsic 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; hemophilia; liver disease and failure; infectious 
processes; bleeding disorders; disseminated intravascular coagulation; lupus erythematosus or other conditions 
associated with circulating inhibitors, e.g., Factor VIII Inhibitor, lupus-like anticoagulant, etc.; sepsis; von 
Willebrand's disease; arterial and venous thrombosis, including the evaluation of hypercoagulable states; 
clinical conditions associated with nephrosis or renal failure; other acquired and congenital coagulopathies as 
well as thrombotic states. 
 
4. A PTT may be used to assess the risk of thrombosis or hemorrhage in patients who are going to have a 
medical intervention known to be associated with increased risk of bleeding or thrombosis. An example is as 
follows: evaluation prior to invasive procedures or operations of patients with personal or family history of 
bleeding or who are on heparin therapy. 
 
You can find this rule in National Coverage Determination (NCD) for Partial Thromboplastin Time (PTT) 
(190.16) - Effective November 25, 2002. 
 
The rules say that the PTT is not useful in monitoring the effects of warfarin on a patient's coagulation 
routinely. However, a PTT may be ordered on a patient being treated with warfarin as heparin therapy is being 
discontinued. A PTT may also be indicated when the PT is markedly prolonged due to warfarin toxicity. The 
need to repeat this test is determined by changes in the underlying medical condition and/or the dosing of 
heparin. 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 National Coverage Determination (NCD) for Partial 
ThromboplastinTime (PTT) (190.16) - Effective November 25, 2002. 
 
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.