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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 a bacterial urine culture is a laboratory procedure performed on a urine specimen to establish
the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a
urine culture. A urine culture may also be used as part of the evaluation and management of another related
condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms
present, and quantification of types present based on morphologic criteria. Isolates deemed significant may be
subjected to additional identification and susceptibility procedures as requested by the ordering physician. The
physician's request may be through clearly documented and communicated laboratory protocols. The
indications are:
1. A patient's urinalysis is abnormal suggesting urinary tract infection, for example, abnormal microscopic
(hematuria, pyuria, bacteriuria); abnormal biochemical urinalysis (positive leukocyte esterase, nitrite, protein,
blood); a Gram's stain positive for microorganisms; positive bacteriuria screen by a non-culture technique; or
other significant abnormality of a urinalysis. While it is not essential to evaluate a urine specimen by one of
these methods before a urine culture is performed, certain clinical presentations with highly suggestive signs
and symptoms may lend themselves to an antecedent urinalysis procedure where follow-up culture depends
upon an initial positive or abnormal test result.
2. A patient has clinical signs and symptoms indicative of a possible urinary tract infection (UTI). Acute lower
UTI may present with urgency, frequency, nocturia, dysuria, discharge or incontinence. These findings may
also be noted in upper UTI with additional systemic symptoms (for example, fever, chills, lethargy); or pain in
the costovertebral, abdominal, or pelvic areas. Signs and symptoms may overlap considerably with other
inflammatory conditions of the genitourinary tract (for example, prostatitis, urethritis, vaginitis, or cervicitis).
Elderly or immunocompromised patients, or patients with neurologic disorders may present atypically (for
example, general debility, acute mental status changes, declining functional status).
3. The patient is being evaluated for suspected urosepsis, fever of unknown origin, or other systemic
manifestations of infection but without a known source. Signs and symptoms used to define sepsis have been
well established.
4. A test-of cure is generally not indicated in an uncomplicated infection. However, it may be indicated if the
patient is being evaluated for response to therapy and there is a complicating co-existing urinary abnormality
including structural or functional abnormalities, calculi, foreign bodies, or ureteral/renal stents or there is
clinical or laboratory evidence of failure to respond as described in Indications 1 and 2.
5. In surgical procedures involving major manipulations of the genitourinary tract, preoperative examination to
detect occult infection may be indicated in selected cases (for example, prior to renal transplantation,
manipulation or removal of kidney stones, or transurethral surgery of the bladder or prostate).
6. Urine culture may be indicated to detect occult infection in renal transplant recipients on immunosuppressive
therapy.
You can find this rule in National Coverage Determination (NCD) for Urine Culture, Bacterial (190.12) -
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.