Date - Current Version Implementation. Date - First Implementationby - CO 7/1/ /9/2012 7/1/2013 7/1/2013 4/16/2013 4/1/2016 1/1/2013 1/1/2013

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1 State: Nevada Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines NEVADA Updated January 2, 2018 NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered Adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider s claims when a provider s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are Adopted for those purposes. State CG number CG title CG Category Date - First Implementationby - CO Date - Current Version Implementation Special Notes CG-ANC-04 CG-ANC-06 CG-BEH-01 Ambulance Services: Air and Water Ambulance Services: Ground, Non- Emergent 12/1/2014 Screening and Assessment Tools for Autism, Asperger s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (NOS) CG-BEH-03 CG-BEH-04 CG-BEH-05 CG-DME-01 CG-DME-07 Psychiatric Disorder Treatment 9/9/2016 Substance-Related and Addictive Disorder Treatment 2/4/2016 Eating and Feeding Disorder Treatment 2/4/2016 External (Portable)Continuous Insulin Infusion Pump Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Pre-service E1902, E2351 Post Service: CPT Codes 92605, 92606, 92607, 92608, 92609; HCPCS Code V5336 CG-DME-10 CG-DME-31 CG-DME- 33 Durable Medical Equipment Power Wheeled Mobility Devices Wheeled Mobility Devices: Ultra lightweight manual wheelchairs CG-DME-40 CG-DME-41 CG-DRUG-01 CG-DRUG-03 CG-DRUG-05 CG-DRUG-08 CG-DRUG-09 CG-DURG-11 CG-DRUG-16 CG-DRUG-24 CG-DRUG-25 CG-DRUG-28 CG-DRUG-29 CG-DRUG-38 Electical Bone Growth Stimulation Ultraviolet Light Therapy Delivery Devices for Home Use Off-Label Drug and Approved Orphan Drug Use Beta-Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Recombinant Erythropoietin Products Pharmacotherapy for Gaucher Disease Intravenous Immune Globulin Therapy Oral and Injectable Infertility Drugs White Blood Cell Growth Factor 4/1/2016 4/1/2013 Repository Corticotropin Injection (H.P. Acthar Gel) IV vs. Oral Drug Administration in the Outpatient and Home Setting Alglucosidase alfa (Lumizyme, Myozyme ) Hyaluronan Injections in the Knee Premetrexed Disodium 12/1/2017 1/1/2015 Revised: January 2, 2018 SKJ Page 1 of 6

2 CG-DRUG-42 Asparagine Specific Enzymes 7/1/2015 CG-DRUG-43 Natalizumab, Tysabri 1/1/2017 CG-DRUG-45 Octreotide Acetate (Sandostatin, Sandostatin LAR 3/1/2015 CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection 1/1/2017 CG-DRUG-50 Paclitaxel, protein-bound (Abraxane) 1/1/2017 CG-DRUG-51 Romidepsin (Istodax) 1/1/2017 CO CG-DRUG-54 Agalsidase Beta (Fabrazyme) CG-DRUG-55 Elosulfase Alfa (Vimizim) CG-DRUG-56 Galsulfase (Naglazyme) CG-DRUG-57 Idursulfase (Elaprase) CG-DRUG-58 Laronidase (Aldurzyme) CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non- Oncologic Indications CG-DRUG-62 Fulvestrant (Faslodex) CG-DRUG-63 Levoleucovorin Calcium (Fusilev) CG-DRUG-64 FDA-Approved Biosimilar Products 11/17/2016 CG-DRUG-65 Tumor Necrosis Factor Antagonists CG-DRUG-66 Panitumumab (Vectibix*) CG-DRUG-68 Bevacizumab (Avastin*) CG-DRUG-69 Ustekinumab (Stelara*) CG-DRUG-70 Eribulin mesylate (Halaven*) CG-DRUG-71 Ziv-aflibercept (Zaltrap ) CG-DRUG-72 Pertuzumab (Perjeta ) CG-DRUG-73 Denosumab (Prolia, Xgeva ) CG-DRUG-74 Canakinumab (Ilaris) CG-DRUG-75 Romiplostim (Nplate ) CG-DRUG-76 Plerixafor Injection (Mozobil ) CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo*) CG-DRUG-78 Antihemophilic Factor and Clotting Factors CG-DRUG-79 Siltuximab (Sylvant*) CG-DRUG-80 Cabazitaxel (Jevtana) CG-DRUG-81 Tocilizumab (Actemra*) CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay CG-GENE-02 Analysis of KRAS Status CG-GENE-03 BRAF Mutation Analysis CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules CG-LAB-03 Tropism Testing for HIV Management CG_LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals 2/1/2018 CG-MED-23 Home Health Care 6/1/2014 CG-MED-26 Neonatal Levels of Care 8/12/2013 CG-MED-32 Ancillary Services for Pregnancy Complications CG-MED-37 Intensive Programs for Pediatric Feeding Disorders 4/1/2017 CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry CG-MED-46 CG-MED-53 Ambulatory and Inpatient Video Electroencephalography Cervical Cancer Screening for Women Under 21 Years of Age 2/1/2017 1/1/2018 CG-MED-55 Check0 9/1/2017 Revised: January 2, 2018 SKJ Page 2 of 6

3 CG-MED-58 Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI CG-MED-63 CG-MED-64 Treatment of Hyperhidrosis Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) CG-MED-65 Manipulation Under Anesthesia of the Spine and Joints other than the Knee CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue CG-MED-67 Melanoma Vaccines CG-MED-68 Therapeutic Apheresis CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices (Pre-service L6955) Post Service: CPT Codes 92605, 92606, 92607, 92608, 92609; HCPCS Code V5336 4/15/2014 CG-REHAB-04 Physical Therapy 11/1/2015 CG-REHAB-05 Occupational Therapy 11/1/2015 CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) CG-REHAB-08 Private Duty Nursing in the Home Setting CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift CG-SURG-05 Maze Procedure CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary Spinal Cord Injury CG-SURG-09 Temporomandibular Disorders Pre Service: CPT Codes 20605, 21010, 21050, 21060, 21073, 21116, 21210, 21240, 21242, 21243, 29800, 29804; HCPCS Codes D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7881, D7873, D7874, D7875, D7876, D7877 CG-SURG-12 Penile Prosthesis Implantation CPT Codes 54400, 5401, 54405, 54410, 54411, 54416, CG-SURG-18 Septoplasty 30420, 30520, CG-SURG-24 CG-SURG-27 Functional Endoscopic Sinus Surgery (FESS) Sex Re-Assignment Surgery Pre Service: CPT Codes 54125, 54520, 54690, 55180, 55970, 56625, 55980, 56800, 56805, 57110, 57291, 57292, 57295, 57296, CG- SURG-28 CG-SURG-29 CG-SURG-30 CG-SURG-33 CG-SURG-38 Transcatheter Uterine Artery Embolization Lumbar Discography (Split from CG RAD- 06 5/13/2013 Tonsillectomy for Children Lumbar Fusion and Lumbar Artificial Disc (LAID) 5/13/2013 Lumbar Laminectomy, Hemi- Laminectomy, Laminotomy and/or Discectomy 11/14/2013 CG-SURG-42 Cervical Fusion 5/1/2016 CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the Outpatient Setting 3/1/2016 Revised: January 2, 2018 SKJ Page 3 of 6

4 CG-SURG-47 CG-SURG-48 CG-SURG-53 CG-SURG-54 CG-SURG-60 Surgical Interventions for Scoliosis and Spinal Deformity 6/15/2016 Elective Percutaneous Coronary Interventions (PCI) 3/1/2016 Elective Total Hip Arthroplasty Elective Total Knee Arhtroplasty Cervical Total Disc Arthroplasty 6/15/2016 6/15/2016 CG-SURG-61 CG-SURG-62 CG-SURG-63 CG-SURG-65 CG-SURG-66 CG-SURG-67 Cryosurgical Ablation of Solid Tumors Outside the Liver Radiofrequency Ablation to Treat Tumors Outside the Liver Cardiac Resynchronization Recombinant Human Bone Morphogenetic Protein Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) Treatment of Osteochondral Defects CG-SURG-68 CG-SURG-69 CG-THER-01 Surgical Treatment of Femoroacetabular Impingement Syndrome Meniscal Allograft Transplantation of the Knee Fractionalization and Radiation Therapy in the Treatment of Specified Cancers CG-THER-02 CG-TRANS-02 Special Radiation Physics Consult and Treatment Procedure Kidney Transplantation 3/1/2016 3/1/2016 AIM Radiology Program Guidelines v Effective Date: August 16, adopted for use effective April 1, 2011 Updates to AIM *****Note: The health plan uses diagnostic imaging management guidelines developed by American Imaging Management, Inc. (AIM), a separate company. For certain health plan members, AIM also provides radiology utilization management services******* AIM updates effective 03/01/2016 Head & Neck Imaging CT of the Head CTA of the Head: Cerebrovascular MRI of the Head MRA of the Head: Cerebrovascular CT of the Orbit, Sella Turcica, Posterior Fossa and the Temporal Bone, including Mastoids MRI of the Orbit, Face, Neck CT of the Paranasal Sinus Maxillofacial Area MRI of the Temporomandibular Joints CT of the Neck (Soft Tissue) CTA of the Neck MRA of the Neck Chest Imaging CT of the Chest CTA of the Chest MRI of the Chest MRA of the Chest Cardiac Imaging Coronary Angiography and Cardiac Catheterization in the Outpatient Setting Nuclear Cardiology - Myocardial Perfusion Imaging Nuclear Cardiology - Infarct Imaging CT Cardiac (Structure) MRI Cardiac Cardiac Intervention Elective Percutaneous Coronary Interventions (PCI) Abdominal & Pelvic Imaging CT of the Abdomen MRI of the Abdomen CTA/MRA of the Abdomen CTA of the Abdominal Aorta - Lower Extremity Run-off CT of the Pelvis MRI of the Pelvis CTA/MRA of the Pelvis Revised: January 2, 2018 SKJ Page 4 of 6

5 CT of the Abdomen & Pelvis Combination Spine Imaging CT of the Cervical Spine MRI of the Cervical Spine CT of the Thoracic Spine MRI of the Thoracic Spine CT of the Lumbar Spine MRI of the Lumbar Spine Radiation Fractionalization and Radiation Therapy: Bone metastases and whole breast irradiation following breast conserving surgery Physics consults and treatment procedure Upper Extremity Imaging CT of the Upper Extremity MRI of the Upper Extremity (Any Joint) MRI of the Upper Extremity (Non-Joint) CTA/MRA Upper Extremity Lower Extremity Imaging CT of the Lower Extremity MRI of the Lower Extremity (Joint & Non- Joint) CTA/MRA of the Lower Extremity Anthem Blue Cross De-Adopted (no longer adopted) Corporate Clinical Utilization State Number De-Adopted" Clinical UM Guideline Title CG Category Effective Date CG-ANC-01 Ambulance Services: Ground, Air, Water Date - Current Version Implementation Special Notes CG-DME-03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy CG-DME-04 Electrical Nerve Stimulation, Transcutaneous Percutaneous CG-DME-05 Cervical Traction Devices for Home Use CG-DME-06 Pneumatic Compression Devices CG-DME-08 Infant Home Apnea Monitors CG-DME-09 Continuous Local Deliver of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Post-Operative Period CG-DME-11 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia 7/15/2012 CG-DME-13 Lower Limb Prosthesis 7/15/2012 CG-DME-15 Hospital Beds and Accessories CG-DME-16 Pressure Reducing Support Surfaces - Groups 1 & 2 CG-DME-18 Home Oxygen Therapy CG-DME-19 Therapeutic Shoes, Inserts and/or Modifications for Individuals with Diabetes CG-DME 20 Orthopedic Footwear Revised: January 2, 2018 SKJ Page 5 of 6

6 CG-DME-21 External Infusion Pumps CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthotics (Braces) CG-DME-23 Patient Lifts CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight 8/8/2013 CG-DME-25 Seat Lift Mechanisms CG-DME-26 Back-Up Ventilators in the Home Setting CG-DME-30 Prothrombin Time Self-Monitoring Devices CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories CG-DRUG-04 Use of Low Molecular Weight Heparin Therapy & Fondaparinux(Arixtra) in the Outpatient setting CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults CG-DRUG-15 Gonadotropin Releasing Hormone Analogs CG-DRUG-18 Nesiritude(Natrecor) CG-DRUG-19 Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk Women CG-DRUG-20 Enfuvirtide (FUZEON ) CG-DRUG-21 Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol Dependence CG-DRUG-27 Clostridial Collagenase Histolyticum Injection CG-DRUG-46 Fosaprepitant (Emend) 4/1/2016 CG-MED-02 Esophageal ph Monitoring CG-MED-21 Anesthesia Service and Moderate ( conscious Sedation ) CG-MED-22 Neuropsychological Testing 5/13/2013 CG-MED-29 Inpatient Subacute Care CG-MED-31 Skilled Nursing Facility CG-MED 43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing(MWT) 7/1/2015 CG-OR-PR-03 Custom-made Knee Braces CG-REHAB-03 Pulmonary Rehabilitation CG-REHAB-06 Speech-Language Pathology CG-REHAB-09 Acute Inpatient Rehabilitation CG-SURG-01 Colonoscopy CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib (VEPTR) CG-SURG-15 Endometrial Ablation Revised: January 2, 2018 SKJ Page 6 of 6