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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 services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that the following are indications for urine culture: 
 
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 the Medicare National Coverage Determination (NCD) for Urine Culture, Bacterial, 
Section 190.12. 
 
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.