Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)husky_health PT/INR monitor Prior Auth | OpenPayer
    Ask Trek AI about this page
    Currenthusky_healthPolicy N/A

    PT/INR MONITORS

    Customize your policy alerts

    Sign up for all husky_health policy alerts

    Know when husky_health releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Policy governing prior authorization, documentation, and coverage criteria for PT/INR monitors and replacements for HUSKY Health (Connecticut Medicaid) members; applies to providers participating in the Connecticut Medical Assistance Program (CMAP).

    Policy Summary
    Payerhusky_health
    PolicyPT/INR MONITORS
    Policy CodePolicy N/A
    Change TypeRevised & Clarified
    Effective DateNov 1, 2024
    Last ReviewSep 23, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a completed request with a prescription and provider documentation dated within 6 months; bill approvals using HCPCS E1399.
    SourceLink
    POLICY UPDATE CHANGES

    Procedure updated to require a prescription dated within six (6) months of the request and documentation from the treating provider supporting the medical need of INR/PT monitor dated within six (6) months.

    InterQual criteria are used for prior authorization review and requests meeting InterQual will be approved using HCPCS E1399 because G0249 is not payable under CMAP.

    Prior authauthorization requirement
    6 morecency of prescription required
    malfunction + OOWreplacement condition

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    E1399billing code to use for approvals

    Coverage and Medical Necessity Criteria

    Medical necessity criteria (initial and replacement)

    Covered when ALL of the following are met and prior authorization is approved per InterQual criteria:

    Prior authorization for an initial PT/INR monitor or replacement is obtained.

    Requests meeting InterQual criteria will be approved and should be billed using HCPCS E1399 (G0249 is not payable under CMAP).

    Authorization request: A fully completed authorization request submitted via the online web portal.
    Signed prescription: A signed prescription from the ordering physician, APRN, or PA enrolled in CMAP dated within the past 6 months.within 6 months
    Provider documentation: Documentation from the ordering provider dated within the past 6 months supporting the medical need for the PT/INR monitor or replacement.within 6 months
    Education and competency: Documentation that the individual and/or caregiver received face-to-face education on anticoagulation management at home and demonstrates ability to correctly use the PT/INR monitor.
    Replacement-specific: For replacements only: documentation that the PT/INR monitor is malfunctioning, is out of warranty (warranty expiration alone is not sufficient), and cannot be repaired.

    Replacement of a PT/INR monitor requires documentation that the device is malfunctioning, is out of warranty, and cannot be repaired; expiration of warranty alone is not considered an automatic reason for replacement.

    There are no additional limitations listed under the Limitations section of this policy (the document indicates “N/A”).

    Billing Codes and Prescription Recency

    Covered HCPCS (miscellaneous DME)HCPCSCovered
    E1399Durable medical equipment, miscellaneous
    Prescription/documentation recency
    Required recency for prescriptionA signed prescription must be dated within the past six (6) months from an ordering physician, APRN, or PA enrolled in CMAP.
    Provider documentation recencyDocumentation from the ordering provider supporting medical need must be dated within the past six (6) months.
    Authorization submissionA fully completed authorization request must be submitted via the online web portal alongside the prescription and supporting documentation.
    Replacement-specific documentationFor replacements, evidence that the device is malfunctioning, out of warranty, and cannot be repaired must accompany the request; warranty expiration alone is not sufficient.

    Prior Authorization, Billing, and Provider Responsibilities

    Prior Authorization

    Obtain prior authorization and bill approvals under E1399

    Prior authorization is required for initial PT/INR monitors and replacements. Requests that meet InterQual criteria will be approved and should be billed using HCPCS E1399 (G0249 is not payable under CMAP).

    • Use HCPCS E1399 for approvals per policy guidance.
    Billing Rule

    Billing highlight: device classification and code to use

    Ensure the PT/INR monitor is documented as a home-use DME item and that HCPCS E1399 is used for billing approvals because G0249 is not payable under Connecticut Medicaid.

    • Recognize device definition and home-use expectations as described in the policy.

    DME-Specific Medical Necessity Determination

    DME-specific medical necessity

    Medical necessity for initial issuance or replacement is determined when all procedural documentation and InterQual criteria are met:

    InterQual criteria: Request meets InterQual criteria used by HUSKY Health for PT/INR monitor prior authorization reviews.

    Approvals use HCPCS E1399 when InterQual criteria are met.

    Provider education: Individual or caregiver demonstrates competency after face-to-face education on home anticoagulation management.

    Documentation of education and demonstrated ability must be provided.

    Documentation Requirements

    Documentation Required

    Documentation required with prior authorization; replacement proof required

    Include documentation with the prior authorization request; for replacements specifically, submit evidence that the PT/INR monitor is malfunctioning, out of warranty, and cannot be repaired (warranty expiration alone is not sufficient).

    • Provide replacement-specific evidence: malfunction, out-of-warranty status, and lack of reparability.

    Rental and Purchase Details

    EquipmentRental vs Purchase RuleNotes
    PT/INR monitorNeutral — policy does not specify distinct rental or purchase pathwaysApprovals are issued using HCPCS E1399 (Durable medical equipment, miscellaneous); document-specific rental vs purchase instructions are not provided in the policy.

    Replacement Policy

    Replacement specifics — PT/INR monitor
    Replacement justificationReplacements require documentation that the PT/INR monitor is malfunctioning, is out of warranty, and cannot be repaired.
    Warranty expiration noteExpiration of the warranty alone is not considered an automatic reason for replacement.
    Required accompanying materialsReplacement requests must include the fully completed authorization request, recent prescription, provider documentation of medical need, and pricing information per DSS Pricing Policy for MEDS items.

    Background and Device Description

    A PT/INR monitor is a battery-operated device used by an individual to self-monitor prothrombin time (PT) and International Normalized Ratio (INR) at home. The device uses a disposable reagent cartridge and a finger‑stick blood collection kit, stores approximately 30–40 recent date/time‑stamped results, and supports trend review to guide anticoagulant dosing either by notifying the medical provider or via a provider‑supervised algorithm.

    Definitions

    PT/INR monitor — definition and description
    Device definitionA battery-operated device used by an individual to self-monitor prothrombin time (PT) and International Normalized Ratio (INR) at home; includes a disposable plastic reagent cartridge and a finger-stick blood collection kit.
    Data storageThe monitor stores between 30 and 40 of the most recent test results, which are date- and time-stamped to enable trend review.
    Use and result handlingAfter testing, the individual notifies the medical provider of results or uses a provider-supervised individualized algorithm to adjust anticoagulant dosing.

    Not Covered Items

    HCPCS code G0249 is not payable under the Connecticut Medical Assistance Program (CMAP). Requests that meet InterQual criteria will be approved and billed using miscellaneous DME code E1399 instead.

    Policy Summary
    Payerhusky_health
    PolicyPT/INR MONITORS
    Policy CodePolicy N/A
    Change TypeRevised & Clarified
    Effective DateNov 1, 2024
    Last ReviewSep 23, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a completed request with a prescription and provider documentation dated within 6 months; bill approvals using HCPCS E1399.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaBilling Codes and Prescription RecencyPrior Authorization, Billing, and Provider ResponsibilitiesDME-Specific Medical Necessity DeterminationDocumentation RequirementsRental and Purchase DetailsReplacement PolicyBackground and Device DescriptionDefinitionsNot Covered Items
    Documentation Required

    Required documentation checklist for authorization

    Include all required documentation with the authorization request: a fully completed online authorization, a signed prescription dated within the past six months, provider documentation of medical need dated within six months, education/competency evidence, pediatric specialist management when applicable, replacement justification when applicable, and DSS pricing information for MEDS items.

    • Fully completed authorization request submitted via the online web portal.
    • Signed prescription from an enrolled ordering physician, APRN, or PA dated within the past six (6) months.
    • Documentation from the ordering provider dated within the past six (6) months supporting medical need.
    • Documentation that the individual/caregiver received face-to-face education and demonstrates ability to use the monitor.
    • For ages ≥3 months and <18 years: documentation of long-term management by a pediatric hematologist or treating provider in consultation with a hematologist.
    • For replacements: documentation the device is malfunctioning, out of warranty (warranty expiration alone is insufficient), and cannot be repaired.
    • Pricing information per DSS Pricing Policy for MEDS Items.
    Denial Risk

    Triggers for denial: missing authorization or documentation

    Requests lacking prior authorization or missing any required documentation may be denied; replacement requests without evidence the device is malfunctioning, out of warranty, and non-repairable are at risk for denial.

    • Missing a fully completed authorization request or a signed prescription within six months risks denial.
    • Absence of provider documentation supporting medical need or education/competency documentation may lead to denial.
    • Replacement requests based solely on warranty expiration (without malfunction/out-of-warranty/non-repairable evidence) may be denied.