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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 basic plasma coagulation function is readily assessed with a few simple laboratory tests: the 
PTT, prothrombin time (PT), thrombin time (TT), or a quantitative fibrinogen determination. The PTT test is 
an in vitro laboratory test used to assess the intrinsic coagulation pathway and monitor heparin therapy. 
 
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 information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-03, National Coverage Determinations (NCD) Manual: Partial Thromboplastin Time (PTT), 
NCD 160.19. 
 
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.