Clinical UM Guideline

This document addresses outpatient urine culture testing for bacteria.

Medically Necessary:

Outpatient urine culture testing for bacteria is considered medically necessary to evaluate any of the following situations:

1. Clinical signs or symptoms suggesting urinary tract infection (UTI); or
2. Abnormal urinalysis suggesting UTI; or
3. Asymptomatic bacteriuria in pregnant persons; or
4. Bacteriuria in individuals prior to undergoing an endoscopic urologic procedure; or
5. Suspected interstitial cystitis or bladder pain syndrome.

Not Medically Necessary:

Outpatient urine culture testing for bacteria is considered not medically necessary when the above criteria are not met and for all other situations.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When services are Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed..

A urine culture is a laboratory test done on a urine sample to check for germs in the urinary tract to find the cause of a presumed UTI. A urine sample can be obtained by a clean catch using a special kit to collect the urine or by insertion of a catheter through the urethra into the bladder. The urine sample is sent to a laboratory to see if there is bacteria or yeast present.

The presence of germs or bacteria in the urine can lead to a UTI. A UTI can occur in any part of the urinary system including the kidneys, ureters, bladder, and urethra. Clinical symptoms of a UTI can include dysuria, nocturia, frequent urination, feeling the need to urinate despite having an empty bladder, hematuria, pressure or cramping in the lower abdomen or groin, fever, chills, lower back pain, and nausea or vomiting.

The American Urological Association 2020 guideline for microhematuria recommends those suspected of having a UTI undergo a urine culture.

Another laboratory test done on a urine sample is a urinalysis. Oftentimes a urinalysis is done prior to a urine culture. With a urinalysis, a urine sample is analyzed visually, with a dipstick, and microscopically. Urinalysis results are typically quicker than urine culture. If urinalysis results are abnormal, a urine culture may be the next step. Examples of abnormal microscopic urinalysis findings include microscopic hematuria, pyuria, or bacteriuria. Examples of abnormal biochemical urinalysis findings include positive leukocyte esterase, presence of nitrites, and proteinuria.

Inappropriate antimicrobial use leads to the risk of antimicrobial resistance. It is important to treat known bacterial infections appropriately. However, not all those who have bacteria in their urine have symptoms. Most asymptomatic individuals would not require urine screenings. The Infectious Diseases Society of America (2019) published their guideline on Management of Asymptomatic Bacteriuria. They give a strong recommendation to screen pregnant persons with urine culture early in pregnancy, even if the pregnant person does not have any signs or symptoms of bacteriuria. There may be a reduced risk of preterm labor, low birth weight, and pyelonephritis after treatment with antimicrobials. The U.S. Preventive Services Task Force (USPSTF) also issued recommendations in 2019. They recommend using urine culture to screen for asymptomatic bacteriuria in pregnant persons (Grade B recommendation).

There may be other instances when urine cultures are done for asymptomatic bacteriuria and treatment is given prophylactically. Sepsis is a potentially serious postoperative complication from endoscopic urologic procedures. Examples include cystoscopy, ureteroscopy, and lithotripsy. For individuals who have bacteriuria, these procedures are in a highly contaminated surgical field. Screening using urine culture and treatment for asymptomatic bacteriuria prior to surgery is strongly recommended by the Infectious Diseases Society of America 2019 guideline on Management of Asymptomatic Bacteriuria.

A 2022 guideline issued by the American Urological Association for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (Clemens, 2022) defines interstitial cystitis/bladder pain syndrome as:

An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes.

The hallmark symptom of interstitial cystitis or bladder pain syndrome is pain. The pain can be in the suprapubic region, throughout the pelvis, and in the lower abdomen and back. Symptoms may also include urinary urgency or frequency and diagnosis can be challenging. The 2022 guideline by the American Urological Association for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome recommends urine culture even in those individuals who have a negative urinalysis. This is to assist in the detection of lower levels of bacteria which may be present in the urine but not identifiable with a urinalysis (dipstick or microscopic exam). Another 2022 guideline issued by the European Association of Urology on Chronic Pelvic Pain also recommends urine culture for those suspected of having bladder pain syndrome.

Bacteriuria: The presence of bacteria in the urine.

Dysuria: Pain or burning while urinating.

Hematuria: Blood in the urine.

Leukocyte esterase: A chemical assay to look for the presence of lysed or intact white blood cells in the urine.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.

Nitrites: When bacteria in the urine changes a normal chemical called nitrates into another chemical.

Nocturia: Waking up during the night to urinate.

Proteinuria: The presence of a high level of protein in the urine.

Pyuria: The presence of white blood cells in the urine.

Urinary tract infection: Refers to an infection of any part of the urinary system (kidneys, ureters, bladder, urethra).

Peer Reviewed Publications:

1. Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehensive review. Am Fam Physician. 2005; 71(6):1153-1162.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020; 204(4):778-786.
2. Clemens JQ, Erickson DR, Varela NP et al. Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol. 2022; 208(1):34-42.
3. European Association of Urology. Guideline on Chronic Pelvic Pain, 2022. Available at: https://d56bochluxqnz.cloudfront.net/documents/full-guideline/EAU-Guidelines-on-Chronic-Pelvic-Pain-2022_2022-03-29-084111_kpbq.pdf. Accessed on September 21, 2023.
4. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis. 2019; 68(10):e83-e110.
5. U.S. Preventive Services Task Force (USPSTF). Asymptomatic bacteriuria in adults: screening. 2019. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/asymptomatic-bacteriuria-in-adults-screening. Accessed on September 21, 2023.

1. National Institute of Diabetes and Digestive and Kidney Diseases. Bladder Infection (Urinary Tract Infection – UTI) in Adults. Available at: https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-infection-uti-in-adults. Accessed on September 21, 2023.

Urine culture

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