Appeal type: unknown
Decision: unknown

 
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 Indications and Limitations of Coverage 
 
Indications 
 
   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. 
 
Limitations 
 
    1. CPT 87086 may be used one time per encounter. 
    2. Colony count restrictions on coverage of CPT 87088 do not apply as they may be highly variable 
according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, degree 
of hydration). 
    3. CPT 87088, 87184, and 87186 may be used multiple times in association with or independent of 87086, as 
urinary tract infections may be polymicrobial. 
    4. Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate but is 
considered screening and, therefore, not covered by Medicare. The US Preventive Services Task Force has 
concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is 
generally not indicated. There are insufficient data to recommend screening in ambulatory elderly patients 
including those with diabetes. Testing may be clinically indicated on other grounds including likelihood of 
recurrence or potential adverse effects of antibiotics, but is considered screening in the absence of clinical or 
laboratory evidence of infection. You can find this information in Medicare's National Coverage Determination 
(NCD): Urine Culture, Bacterial (190.12). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.