Medicare considers a [name of test] to be frequency restricted. This means that Medicare may decide to deny payment for [name of test] if you have had it within the past [time period as indicated by First Comply software]. However, depending on your diagnosis and medications that you are on, this test may be covered more frequently than indicated by Medicare.

This document is an advance beneficiary notice, which is also referred to as an ABN. This notice gives you the right to accept or decline the test based on the fact that it is a frequency-restricted test. The estimated cost of the test is [amount].