Texas Prior Authorization Program Clinical Criteria. Revisions were recommended by MCOs and VDP to ensure appropriate utilization.

Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Growth Hormone Revisions were recommended by MCOs and VDP to ensure appropriate utilization. Clinical PA Information Included in this Document Growth Hormone Agents - Excluding Serostim / Zorbtive Serostim Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable Note: Click the hyperlink to navigate directly to that section. May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 1

Zorbtive Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated Criteria Guide with DUR Board Recommendations, including testing criteria Updated Serostim criteria logic, page 78. Question 4 now asks for claims for 2 or more single ingredient antiretroviral agents OR 1 claim for a combination ingredient antiretroviral agent in the last 90 days Updated Serostim criteria logic diagram, page 79 Updated Table 4, pages 80-83. Table 4a contains single ingredient antiretroviral agents and Table 4b contains combination ingredient antiretroviral agents May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 2

Growth Hormone Excluding Serostim / Zorbtive Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN GENOTROPIN 12 MG CARTRIDGE 10554 GENOTROPIN MINIQUICK 0.2 MG 50177 GENOTROPIN MINIQUICK 0.4 MG 50187 GENOTROPIN MINIQUICK 0.8 MG 50207 GENOTROPIN MINIQUICK 1.2 MG 21450 GENOTROPIN MINIQUICK 1.4 MG 21451 GENOTROPIN MINIQUICK 1.6 MG 21452 GENOTROPIN MINIQUICK 1.8 MG 21453 GENOTROPIN MINIQUICK 2 MG 21454 GENOTROPIN MINIQUICK 0.6 MG 50197 GENOTROPIN 5 MG CARTRIDGE 63408 GENOTROPIN MINIQUICK 1 MG 50217 HUMATROPE 5 MG VIAL 25963 HUMATROPE 6 MG CARTRIDGE 25969 HUMATROPE 12 MG CARTRIDGE 00575 HUMATROPE 24 MG CARTRIDGE 25957 NORDITROPIN NORDIFLEX 30 MG/3 25816 NORDITROPIN FLEXPRO 5 MG/1.5 24145 NORDITROPIN FLEXPRO 15 MG/1.5 24147 NORDITROPIN FLEXPRO 10 MG/1.5 24146 NUTROPIN AQ PEN CARTRIDGE 17475 NUTROPIN AQ 20 MG/2ML PEN CART 99320 NUTROPIN AQ NUSPIN 10 INJECTOR 39695 NUTROPIN AQ NUSPIN 5 INJECTOR 27846 NUTROPIN AQ NUSPIN 20 INJECTOR 39698 OMNITROPE 5 MG/1.5 ML CRTG 92386 OMNITROPE 10 MG/1.5 ML CRTG 92366 OMNITROPE 5.8 MG VIAL 93215 SAIZEN 5 MG VIAL 25955 SAIZEN 8.8 MG CLICK EASY CARTG 23695 SAIZEN 8.8 MG VIAL 12767 TEV-TROPIN 5 MG VIAL 25955 May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 3

Growth Hormone Excluding Serostim / Zorbtive Clinical PA Criteria Logic 1. Is the client 0 to 16 (> 0 and 16) years of age? [ ] Yes (Go to #2) [ ] No (Go to #7) 2. Does the client have a diagnosis of growth hormone deficiency (GHD) or idiopathic short stature (ISS) in the last 3 years? [ ] Yes (Go to #6) [ ] No (Go to #3) 3. Does the client have a diagnosis of panhypopituitarism, SHOX deficiency, Turner syndrome, Noonan syndrome or Prader-Willi syndrome in the last 3 years? [ ] Yes (Go to #11) [ ] No (Go to #4) 4. Does the client have a diagnosis of chronic kidney disease (CKD) in the last 3 years? [ ] Yes (Go to #5) [ ] No (Deny) 5. Does the client have a history of a renal transplant (CPT) in the last 3 years? [ ] Yes (Deny) [ ] No (Go to #6) 6. Does the submitted documentation support the requested diagnosis? [MANUAL] [ ] Yes (Go to #11) [ ] No (Deny) 7. Does the client have a diagnosis of panhypopituitarism in the last 3 years? [ ] Yes (Go to #9) [ ] No (Go to #8) 8. Does the client have a diagnosis of GHD or ISS in the last 3 years? [ ] Yes (Go to #10) [ ] No (Deny) 9. Has the client had at least 2 claims for the requested medication in the last 90 days (stable therapy)? [ ] Yes (Go to #11) [ ] No (Go to #10) May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 4

10.Does the submitted documentation support the requested diagnosis? [MANUAL] [ ] Yes (Go to #11) [ ] No (Deny) 11.Does the client have a diagnosis of active malignancy in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #12) 12.Does the client have a history of chemotherapy/radiation (CPTs) in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #13) 13.Does the client have a diagnosis of active proliferative or severe nonproliferative diabetic retinopathy in the last 365 days? [ ] Yes (Deny) [ ] No (Approve 365 days) May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 5

Growth Hormone Excluding Serostim / Zorbtive Clinical Criteria PA Logic Diagram Step 1 Step 2 Step 3 Step 4 Is the client between 0 and 16 years of age? Yes Does the client have a diagnosis of GHD or ISS in the last 3 years? No Does the client have a diagnosis of panhypopituitarism, SHOX deficiency, Turner syndrome, Noonan syndrome or Prader-Willi syndrome in the last 3 years? No Does the client have a diagnosis of CKD in the last 3 years? No Deny Request No Yes Yes Yes Go to Step 7 Step 6 Does the submitted documentation support the requested diagnosis? [MANUAL] Go to Step 11 Step 5 Does the client have a history of renal transplant in the last 3 years? Yes Deny Request No Yes No Deny Request Go to Step 11 Go to Step 6 Step 7 Step 9 Step 10 Does the client have a diagosis of panhypopituitarism in the last 3 years? Yes Has the client been stable ( 2 claims in the last 90 days) on the requested medication? No Does the submitted documentation support the requested diagnosis? [MANUAL] No Deny Request No Yes Yes Step 8 Step 11 Step 12 Step 13 Does the client have a diagnosis of GHD or ISS in the last 3 years? Does the client have a diagnosis of active malignancy in the last 180 days? No Does the client have a history of chemotherapy/ radiation the last 180 days? No Does the client have a history of active proliferative or severe non-proliferative diabetic retinopathy in the last 365 days? No Approve Request (365 days) Yes No Yes Yes Yes Go to Step 10 Deny Request Deny Request Deny Request May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 6

Growth Hormone Excluding Serostim / Zorbtive Clinical PA Criteria Supporting Tables Step 2 (diagnosis of GHD or ISS) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2533 PITUITARY DWARFISM 76490 FET GROWTH RETARD WT NOS 76491 FET GROWTH RETARD <500G 76492 FET GROWTH RET 500-749G 76493 FET GROWTH RET 750-999G 76494 FET GRWTH RET 1000-1249G 76495 FET GRWTH RET 1250-1499G 76496 FET GRWTH RET 1500-1749G 76497 FET GRWTH RET 1750-1999G 76498 FET GRWTH RET 2000-2499G 76499 FET GROWTH RET 2500+G 78343 SHORT STATURE ICD-10 Code Description E343 SHORT STATURE DUE TO ENDOCRINE DISORDER P059 NEWBORN AFFECTED BY SLOW INTRAUTERINE GROWTH, UNSPECIFIED R6252 SHORT STATURE (CHILD) Step 3 (diagnosis of panhypopituitarism, SHOX deficiency, Turner syndrome, Noonan syndrome or Prader-Willi syndrome) ICD-9 Code Description 2532 PANHYPOPITUITARISM 2533 PITUITARY DWARFISM Required diagnosis: 1 Look back timeframe: 3 years 2537 IATROGENIC PITUITARY DIS 7586 TURNER S SYNDROME (GONADAL DYSGENESIS) 75981 PRADER-WILLI SYNDROME ICD-10 Code E230 E231 Description HYPOPITUITARISM DRUG-INDUCED HYPOPITUITARISM May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 7

E893 Step 3 (diagnosis of panhypopituitarism, SHOX deficiency, Turner syndrome, Noonan syndrome or Prader-Willi syndrome) Q871 Q960 Q961 Q962 Q963 Q964 Q968 Q969 Required diagnosis: 1 Look back timeframe: 3 years POSTPROCEDURAL HYPOPITUITARISM CONGENITAL MALFORMATION SYNDROMES PREDOMINANTLY ASSOCIATED WITH SHORT STATURE KARYOTYPE 45, X KARYOTYPE 46, X ISO (XQ) KARYOTYPE 46, X WITH ABNORMAL SEX CHROMOSOME, EXCEPT ISO (XQ) MOSAICISM, 45, X/46, XX OR XY MOSAICISM, 45, X/OTHER CELL LINE(S) WITH ABNORMAL SEX CHROMOSOME OTHER VARIANTS OF TURNER'S SYNDROME TURNER'S SYNDROME, UNSPECIFIED Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 585 CHRONIC RENAL FAILURE 586 RENAL FAILURE NOS 587 RENAL SCLEROSIS NOS 5810 NEPHROTIC SYN, PROLIFER 5811 EPIMEMBRANOUS NEPHRITIS 5812 MEMBRANOPROLIF NEPHROSIS 5819 NEPHROTIC SYNDROME NOS 5820 CHR PROLIFERAT NEPHRITIS 5821 CHR MEMBRANOUS NEPHRITIS 5822 CHR MEMBRANOPROLIF NEPHR 5824 CHR RAPID PROGR NEPHRIT 5829 CHRONIC NEPHRITIS NOS 5830 PROLIFERAT NEPHRITIS NOS 5831 MEMBRANOUS NEPHRITIS NOS 5832 MEMBRANOPROLIF NEPHR NOS 5834 RAPIDLY PROG NEPHRIT NOS 5836 RENAL CORT NECROSIS NOS 5837 NEPHR NOS/MEDULL NECROS 5839 NEPHRITIS NOS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 8

Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years 5852 CHRONIC KIDNEY DISEASE, STAGE II (MILD). 5853 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE). 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE). 5855 CHRONIC KIDNEY DISEASE, STAGE V. 5856 END STAGE RENAL DISEASE. 5859 CHRONIC KIDNEY DISEASE, UNSPECIFIED. 5880 RENAL OSTEODYSTROPHY 5881 NEPHROGEN DIABETES INSIP 5888 IMPAIRED RENAL FUNCT NEC 5889 IMPAIRED RENAL FUNCT NOS 58181 NEPHROTIC SYN IN OTH DIS 58189 NEPHROTIC SYNDROME NEC 58281 CHR NEPHRITIS IN OTH DIS 58289 CHRONIC NEPHRITIS NEC 58381 NEPHRITIS NOS IN OTH DIS 58389 NEPHRITIS NEC ICD-10 Code B520 E0821 E0822 E0829 E0921 E0922 E0929 M3214 M3215 M3504 N020 N021 N022 N023 Description PLASMODIUM MALARIAE MALARIA WITH NEPHROPATHY DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC NEPHROPATHY DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC CHRONIC KIDNEY DISEASE DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH OTHER DIABETIC KIDNEY COMPLICATION DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH DIABETIC NEPHROPATHY DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION GLOMERULAR DISEASE IN SYSTEMIC LUPUS ERYTHEMATOSUS TUBULO-INTERSTITIAL NEPHROPATHY IN SYSTEMIC LUPUS ERYTHEMATOSUS SICCA SYNDROME WITH TUBULO-INTERSTITIAL NEPHROPATHY RECURRENT AND PERSISTENT HEMATURIA WITH MINOR GLOMERULAR ABNORMALITY RECURRENT AND PERSISTENT HEMATURIA WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 9

N024 N025 N026 N027 N028 N029 N030 N031 N032 N033 N034 N035 N036 N037 N038 N039 N041 N042 N043 N044 N045 N046 N047 N048 N049 N050 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DENSE DEPOSIT DISEASE RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH OTHER MORPHOLOGIC CHANGES RECURRENT AND PERSISTENT HEMATURIA WITH UNSPECIFIED MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY CHRONIC NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES NEPHROTIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS NEPHROTIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DENSE DEPOSIT DISEASE NEPHROTIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES NEPHROTIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES UNSPECIFIED NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 10

N051 N052 N053 N054 N055 N056 N057 N058 N059 N061 N062 N063 N064 N065 N066 N067 N068 N069 N071 N072 N073 N074 N075 N076 N077 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years UNSPECIFIED NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES UNSPECIFIED NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES ISOLATED PROTEINURIA WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS ISOLATED PROTEINURIA WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DENSE DEPOSIT DISEASE ISOLATED PROTEINURIA WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH OTHER MORPHOLOGIC LESION ISOLATED PROTEINURIA WITH UNSPECIFIED MORPHOLOGIC LESION HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DENSE DEPOSIT DISEASE HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 11

N078 N079 N08 N150 N158 N159 N16 N182 N183 N184 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH OTHER MORPHOLOGIC LESIONS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH UNSPECIFIED MORPHOLOGIC LESIONS GLOMERULAR DISORDERS IN DISEASES CLASSIFIED ELSEWHERE BALKAN NEPHROPATHY OTHER SPECIFIED RENAL TUBULO-INTERSTITIAL DISEASES RENAL TUBULO-INTERSTITIAL DISEASE, UNSPECIFIED RENAL TUBULO-INTERSTITIAL DISORDERS IN DISEASES CLASSIFIED ELSEWHERE CHRONIC KIDNEY DISEASE, STAGE 2 (MILD) CHRONIC KIDNEY DISEASE, STAGE 3 (MODERATE) CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) N185 CHRONIC KIDNEY DISEASE, STAGE 5 N186 N189 N19 N250 N251 N259 N261 N269 END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED UNSPECIFIED KIDNEY FAILURE RENAL OSTEODYSTROPHY NEPHROGENIC DIABETES INSIPIDUS DISORDER RESULTING FROM IMPAIRED RENAL TUBULAR FUNCTION, UNSPECIFIED ATROPHY OF KIDNEY (TERMINAL) RENAL SCLEROSIS, UNSPECIFIED Step 5 (history of renal transplant procedural code) Required procedure: 1 Look back timeframe: 3 years CPT Code Description 50300 REMOVAL OF DONOR KIDNEY 50300 REMOVE CADAVER DONOR KIDNEY 50320 REMOVE KIDNEY, LIVING DONOR 50340 REMOVAL OF KIDNEY 50360 TRANSPLANTATION OF KIDNEY 50365 TRANSPLANTATION OF KIDNEY 50370 REMOVE TRANSPLANTED KIDNEY 50380 REIMPLANTATION OF KIDNEY May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 12

Step 6 Testing Requirements Growth Hormone Deficiency, Idiopathic Short Stature, Panhypopituitarism, Chronic Kidney Disease, SHOX deficiency, Turner syndrome, Noonan syndrome and Prader-Willi syndrome in Children Diagnosis Panhypopituitarism Testing Requirements Initiation of GH Therapy: IGF-1 level < 160 ng/ml, AND Failure to respond (response 5ng/mL) to one growth hormone stimulation test (Note: children < 12 months of age are excluded from provocative testing) Growth Hormone Deficiency Idiopathic Short Stature Chronic Kidney Disease SHOX deficiency, Turner syndrome, Noonan syndrome and Prader-Willi syndrome Renewal of GH Therapy: No additional testing is required Initiation of GH Therapy: Failure to respond (response < 10ng/mL) to at least 2 growth hormone stimulation tests (Note: children < 12 months of age are excluded from provocative testing), AND Patient s height > 2.25 SD below the mean for age OR patient s height > 2 SD below the midparental height percentile, AND Growth velocity < 25 th percentile for bone age Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, AND Epiphyses are open Initiation of GH Therapy: Height > 2.25 SD below the mean for age, AND Predicted adult height < 63 inches for males and < 59 inches for females Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, OR show an increase in height velocity of 50%, OR an increase of at least 2.5cm/year above the baseline height velocity, AND Epiphyses are open Initiation of GH Therapy: GFR 75mL/min/1.73m 2, AND Patient s height > 2.25 SD below the mean for age OR patient s height > 2 SD below the midparental height percentile OR patient s Z score < -1.88, AND Pre-transplant Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, AND Pre-transplant, AND Epiphyses are open Diagnosis only is required, no additional testing is requested May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 13

Step 7 (diagnosis of panhypopituitarism) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2532 PANHYPOPITUITARISM 2533 PITUITARY DWARFISM 2537 IATROGENIC PITUITARY DISORDERS ICD-10 Code Description E230 HYPOPITUITARISM E893 POSTPROCEDURAL HYPOPITUITARISM Step 8 (diagnosis of GHD or ISS) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2533 PITUITARY DWARFISM 76490 FET GROWTH RETARD WT NOS 76491 FET GROWTH RETARD <500G 76492 FET GROWTH RET 500-749G 76493 FET GROWTH RET 750-999G 76494 FET GRWTH RET 1000-1249G 76495 FET GRWTH RET 1250-1499G 76496 FET GRWTH RET 1500-1749G 76497 FET GRWTH RET 1750-1999G 76498 FET GRWTH RET 2000-2499G 76499 FET GROWTH RET 2500+G 78343 SHORT STATURE ICD-10 Code Description E343 SHORT STATURE DUE TO ENDOCRINE DISORDER P059 NEWBORN AFFECTED BY SLOW INTRAUTERINE GROWTH, UNSPECIFIED R6252 SHORT STATURE (CHILD) May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 14

Step 10 Testing Requirements Panhypopituitarism, Growth Hormone Deficiency or Idiopathic Short Stature Diagnosis Panhypopituitarism in patients > 16 years of age Testing Requirements Initiation of GH Therapy: IGF-1 level < 160 ng/ml, AND Failure to respond to one growth hormone stimulation test (response 5ng/mL) GHD/ISS Renewal of GH Therapy: No additional testing is required Renewal of GH Therapy: If patient has been treated as a pediatric patient ( 16 years of age) and is requesting a refill, patient s growth should exceed 2 cm/year, AND Bone age < 16 years, AND Epiphyses are open ICD-9 Code Description 1400 MAL NEO UPPER VERMILION 1401 MAL NEO LOWER VERMILION 1403 MAL NEO UPPER LIP, INNER 1404 MAL NEO LOWER LIP, INNER 1405 MAL NEO LIP, INNER NOS 1406 MAL NEO LIP, COMMISSURE 1408 MAL NEO LIP NEC 1409 MAL NEO LIP/VERMIL NOS 1410 MAL NEO TONGUE BASE 1411 MAL NEO DORSAL TONGUE 1412 MAL NEO TIP/LAT TONGUE 1413 MAL NEO VENTRAL TONGUE 1414 MAL NEO ANT 2/3 TONGUE 1415 MAL NEO TONGUE JUNCTION 1416 MAL NEO LINGUAL TONSIL 1418 MALIG NEO TONGUE NEC 1419 MALIG NEO TONGUE NOS 1420 MALIG NEO PAROTID 1421 MALIG NEO SUBMANDIBULAR 1422 MALIG NEO SUBLINGUAL 1428 MAL NEO MAJ SALIVARY NEC May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 15

1429 MAL NEO SALIVARY NOS 1430 MALIG NEO UPPER GUM 1431 MALIG NEO LOWER GUM 1438 MALIG NEO GUM NEC 1439 MALIG NEO GUM NOS 1440 MAL NEO ANT FLOOR MOUTH 1441 MAL NEO LAT FLOOR MOUTH 1448 MAL NEO MOUTH FLOOR NEC 1449 MAL NEO MOUTH FLOOR NOS 1450 MAL NEO CHEEK MUCOSA 1451 MAL NEO MOUTH VESTIBULE 1452 MALIG NEO HARD PALATE 1453 MALIG NEO SOFT PALATE 1454 MALIGNANT NEOPLASM UVULA 1455 MALIGNANT NEO PALATE NOS 1456 MALIG NEO RETROMOLAR 1458 MALIG NEOPLASM MOUTH NEC 1459 MALIG NEOPLASM MOUTH NOS 1460 MALIGNANT NEOPL TONSIL 1461 MAL NEO TONSILLAR FOSSA 1462 MAL NEO TONSIL PILLARS 1463 MALIGN NEOPL VALLECULA 1464 MAL NEO ANT EPIGLOTTIS 1465 MAL NEO EPIGLOTTIS JUNCT 1466 MAL NEO LAT OROPHARYNX 1467 MAL NEO POST OROPHARYNX 1468 MAL NEO OROPHARYNX NEC 1469 MALIG NEO OROPHARYNX NOS 1470 MAL NEO SUPER NASOPHARYN 1471 MAL NEO POST NASOPHARYNX 1472 MAL NEO LAT NASOPHARYNX 1473 MAL NEO ANT NASOPHARYNX 1478 MAL NEO NASOPHARYNX NEC 1479 MAL NEO NASOPHARYNX NOS 1480 MAL NEO POSTCRICOID 1481 MAL NEO PYRIFORM SINUS 1482 MAL NEO ARYEPIGLOTT FOLD 1483 MAL NEO POST HYPOPHARYNX 1488 MAL NEO HYPOPHARYNX NEC 1489 MAL NEO HYPOPHARYNX NOS 1490 MAL NEO PHARYNX NOS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 16

1491 MAL NEO WALDEYER'S RING 1498 MAL NEO ORAL/PHARYNX NEC 1499 MAL NEO OROPHRYN ILL-DEF 1500 MAL NEO CERVICAL ESOPHAG 1501 MAL NEO THORACIC ESOPHAG 1502 MAL NEO ABDOMIN ESOPHAG 1503 MAL NEO UPPER 3RD ESOPH 1504 MAL NEO MIDDLE 3RD ESOPH 1505 MAL NEO LOWER 3RD ESOPH 1508 MAL NEO ESOPHAGUS NEC 1509 MAL NEO ESOPHAGUS NOS 1510 MAL NEO STOMACH CARDIA 1511 MALIGNANT NEO PYLORUS 1512 MAL NEO PYLORIC ANTRUM 1513 MAL NEO STOMACH FUNDUS 1514 MAL NEO STOMACH BODY 1515 MAL NEO STOM LESSER CURV 1516 MAL NEO STOM GREAT CURV 1518 MALIG NEOPL STOMACH NEC 1519 MALIG NEOPL STOMACH NOS 1520 MALIGNANT NEOPL DUODENUM 1521 MALIGNANT NEOPL JEJUNUM 1522 MALIGNANT NEOPLASM ILEUM 1523 MAL NEO MECKEL'S DIVERT 1528 MAL NEO SMALL BOWEL NEC 1529 MAL NEO SMALL BOWEL NOS 1530 MAL NEO HEPATIC FLEXURE 1531 MAL NEO TRANSVERSE COLON 1532 MAL NEO DESCEND COLON 1533 MAL NEO SIGMOID COLON 1534 MALIGNANT NEOPLASM CECUM 1535 MALIGNANT NEO APPENDIX 1536 MALIG NEO ASCEND COLON 1537 MAL NEO SPLENIC FLEXURE 1538 MALIGNANT NEO COLON NEC 1539 MALIGNANT NEO COLON NOS 1540 MAL NEO RECTOSIGMOID JCT 1541 MALIGNANT NEOPL RECTUM 1542 MALIG NEOPL ANAL CANAL 1543 MALIGNANT NEO ANUS NOS 1548 MAL NEO RECTUM/ANUS NEC May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 17

1550 MAL NEO LIVER, PRIMARY 1551 MAL NEO INTRAHEPAT DUCTS 1552 MALIGNANT NEO LIVER NOS 1560 MALIG NEO GALLBLADDER 1561 MAL NEO EXTRAHEPAT DUCTS 1562 MAL NEO AMPULLA OF VATER 1568 MALIG NEO BILIARY NEC 1569 MALIG NEO BILIARY NOS 1570 MAL NEO PANCREAS HEAD 1571 MAL NEO PANCREAS BODY 1572 MAL NEO PANCREAS TAIL 1573 MAL NEO PANCREATIC DUCT 1574 MAL NEO ISLET LANGERHANS 1578 MALIG NEO PANCREAS NEC 1579 MALIG NEO PANCREAS NOS 1580 MAL NEO RETROPERITONEUM 1588 MAL NEO PERITONEUM NEC 1589 MAL NEO PERITONEUM NOS 1590 MALIG NEO INTESTINE NOS 1591 MALIGNANT NEO SPLEEN NEC 1598 MAL NEO GI/INTRA-ABD NEC 1599 MAL NEO GI TRACT ILL-DEF 1600 MAL NEO NASAL CAVITIES 1601 MALIG NEO MIDDLE EAR 1602 MAL NEO MAXILLARY SINUS 1603 MAL NEO ETHMOIDAL SINUS 1604 MALIG NEO FRONTAL SINUS 1605 MAL NEO SPHENOID SINUS 1608 MAL NEO ACCESS SINUS NEC 1609 MAL NEO ACCESS SINUS NOS 1610 MALIGNANT NEO GLOTTIS 1611 MALIG NEO SUPRAGLOTTIS 1612 MALIG NEO SUBGLOTTIS 1613 MAL NEO CARTILAGE LARYNX 1618 MALIGNANT NEO LARYNX NEC 1619 MALIGNANT NEO LARYNX NOS 1620 MALIGNANT NEO TRACHEA 1622 MALIG NEO MAIN BRONCHUS 1623 MAL NEO UPPER LOBE LUNG 1624 MAL NEO MIDDLE LOBE LUNG 1625 MAL NEO LOWER LOBE LUNG May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 18

1628 MAL NEO BRONCH/LUNG NEC 1629 MAL NEO BRONCH/LUNG NOS 1630 MAL NEO PARIETAL PLEURA 1631 MAL NEO VISCERAL PLEURA 1638 MALIG NEOPL PLEURA NEC 1639 MALIG NEOPL PLEURA NOS 1640 MALIGNANT NEOPL THYMUS 1641 MALIGNANT NEOPL HEART 1642 MAL NEO ANT MEDIASTINUM 1643 MAL NEO POST MEDIASTINUM 1648 MAL NEO MEDIASTINUM NEC 1649 MAL NEO MEDIASTINUM NOS 1650 MAL NEO UPPER RESP NOS 1658 MAL NEO THORAX/RESP NEC 1659 MAL NEO RESP SYSTEM NOS 1700 MAL NEO SKULL/FACE BONE 1701 MALIGNANT NEO MANDIBLE 1702 MALIG NEO VERTEBRAE 1703 MAL NEO RIBS/STERN/CLAV 1704 MAL NEO LONG BONES ARM 1705 MAL NEO BONES WRIST/HAND 1706 MAL NEO PELVIC GIRDLE 1707 MAL NEO LONG BONES LEG 1708 MAL NEO BONES ANKLE/FOOT 1709 MALIG NEOPL BONE NOS 1710 MAL NEO SOFT TISSUE HEAD 1712 MAL NEO SOFT TISSUE ARM 1713 MAL NEO SOFT TISSUE LEG 1714 MAL NEO SOFT TIS THORAX 1715 MAL NEO SOFT TIS ABDOMEN 1716 MAL NEO SOFT TIS PELVIS 1717 MAL NEOPL TRUNK NOS 1718 MAL NEO SOFT TISSUE NEC 1719 MAL NEO SOFT TISSUE NOS 1720 MALIG MELANOMA LIP 1721 MALIG MELANOMA EYELID 1722 MALIG MELANOMA EAR 1723 MAL MELANOM FACE NEC/NOS 1724 MAL MELANOMA SCALP/NECK 1725 MALIG MELANOMA TRUNK 1726 MALIG MELANOMA ARM May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 19

1727 MALIG MELANOMA LEG 1728 MALIG MELANOMA SKIN NEC 1729 MALIG MELANOMA SKIN NOS 1730 MALIG NEO SKIN LIP 1731 MALIG NEO SKIN EYELID 1732 MALIG NEO SKIN EAR 1733 MAL NEO SKIN FACE NEC 1734 MAL NEO SCALP/SKIN NECK 1735 MALIG NEO SKIN TRUNK 1736 MALIG NEO SKIN ARM 1737 MALIG NEO SKIN LEG 1738 MALIG NEO SKIN NEC 1739 MALIG NEO SKIN NOS 1740 MALIG NEO NIPPLE 1741 MAL NEO BREAST-CENTRAL 1742 MAL NEO BREAST UP-INNER 1743 MAL NEO BREAST LOW-INNER 1744 MAL NEO BREAST UP-OUTER 1745 MAL NEO BREAST LOW-OUTER 1746 MAL NEO BREAST-AXILLARY 1748 MALIGN NEOPL BREAST NEC 1749 MALIGN NEOPL BREAST NOS 1750 MAL NEO MALE NIPPLE 1759 MAL NEO MALE BREAST NEC 1760 SKIN - KAPOSI'S SARCOMA 1761 SFT TISUE - KPSI'S SRCMA 1762 PALATE - KPSI's SARCOMA 1763 GI SITES - KPSI'S SRCOMA 1764 LUNG - KAPOSI'S SARCOMA 1765 LYM NDS - KPSI'S SARCOMA 1768 SPF STS - KPSI'S SARCOMA 1769 KAPOSI'S SARCOMA NOS 179 MALIG NEOPL UTERUS NOS 1800 MALIG NEO ENDOCERVIX 1801 MALIG NEO EXOCERVIX 1808 MALIG NEO CERVIX NEC 1809 MAL NEO CERVIX UTERI NOS 181 MALIGNANT NEOPL PLACENTA 1820 MALIG NEO CORPUS UTERI 1821 MAL NEO UTERINE ISTHMUS 1828 MAL NEO BODY UTERUS NEC May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 20

1830 MALIGN NEOPL OVARY 1832 MAL NEO FALLOPIAN TUBE 1833 MAL NEO BROAD LIGAMENT 1834 MALIG NEO PARAMETRIUM 1835 MAL NEO ROUND LIGAMENT 1838 MAL NEO ADNEXA NEC 1839 MAL NEO ADNEXA NOS 1840 MALIGN NEOPL VAGINA 1841 MAL NEO LABIA MAJORA 1842 MAL NEO LABIA MINORA 1843 MALIGN NEOPL CLITORIS 1844 MALIGN NEOPL VULVA NOS 1848 MAL NEO FEMALE GENIT NEC 1849 MAL NEO FEMALE GENIT NOS 185 MALIGN NEOPL PROSTATE 1860 MAL NEO UNDESCEND TESTIS 1869 MALIG NEO TESTIS NEC 1871 MALIGN NEOPL PREPUCE 1872 MALIG NEO GLANS PENIS 1873 MALIG NEO PENIS BODY 1874 MALIG NEO PENIS NOS 1875 MALIG NEO EPIDIDYMIS 1876 MAL NEO SPERMATIC CORD 1877 MALIGN NEOPL SCROTUM 1878 MAL NEO MALE GENITAL NEC 1879 MAL NEO MALE GENITAL NOS 1880 MAL NEO BLADDER-TRIGONE 1881 MAL NEO BLADDER-DOME 1882 MAL NEO BLADDER-LATERAL 1883 MAL NEO BLADDER-ANTERIOR 1884 MAL NEO BLADDER-POST 1885 MAL NEO BLADDER NECK 1886 MAL NEO URETERIC ORIFICE 1887 MALIG NEO URACHUS 1888 MALIG NEO BLADDER NEC 1889 MALIG NEO BLADDER NOS 1890 MALIG NEOPL KIDNEY 1891 MALIG NEO RENAL PELVIS 1892 MALIGN NEOPL URETER 1893 MALIGN NEOPL URETHRA 1894 MAL NEO PARAURETHRAL May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 21

1898 MAL NEO URINARY NEC 1899 MAL NEO URINARY NOS 1900 MALIGN NEOPL EYEBALL 1901 MALIGN NEOPL ORBIT 1902 MAL NEO LACRIMAL GLAND 1903 MAL NEO CONJUNCTIVA 1904 MALIGN NEOPL CORNEA 1905 MALIGN NEOPL RETINA 1906 MALIGN NEOPL CHOROID 1907 MAL NEO LACRIMAL DUCT 1908 MALIGN NEOPL EYE NEC 1909 MALIGN NEOPL EYE NOS 1910 MALIGN NEOPL CEREBRUM 1911 MALIG NEO FRONTAL LOBE 1912 MAL NEO TEMPORAL LOBE 1913 MAL NEO PARIETAL LOBE 1914 MAL NEO OCCIPITAL LOBE 1915 MAL NEO CEREB VENTRICLE 1916 MAL NEO CEREBELLUM NOS 1917 MAL NEO BRAIN STEM 1918 MALIG NEO BRAIN NEC 1919 MALIG NEO BRAIN NOS 1920 MAL NEO CRANIAL NERVES 1921 MAL NEO CEREBRAL MENING 1922 MAL NEO SPINAL CORD 1923 MAL NEO SPINAL MENINGES 1928 MAL NEO NERVOUS SYST NEC 1929 MAL NEO NERVOUS SYST NOS 193 MALIGN NEOPL THYROID 1940 MALIGN NEOPL ADRENAL 1941 MALIG NEO PARATHYROID 1943 MALIG NEO PITUITARY 1944 MALIGN NEO PINEAL GLAND 1945 MAL NEO CAROTID BODY 1946 MAL NEO PARAGANGLIA NEC 1948 MAL NEO ENDOCRINE NEC 1949 MAL NEO ENDOCRINE NOS 1950 MAL NEO HEAD/FACE/NECK 1951 MALIGN NEOPL THORAX 1952 MALIG NEO ABDOMEN 1953 MALIGN NEOPL PELVIS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 22

1954 MALIGN NEOPL ARM 1955 MALIGN NEOPL LEG 1958 MALIG NEO SITE NEC 1960 MAL NEO LYMPH-HEAD/NECK 1961 MAL NEO LYMPH-INTRATHOR 1962 MAL NEO LYMPH INTRA-ABD 1963 MAL NEO LYMPH-AXILLA/ARM 1965 MAL NEO LYMPH-INGUIN/LEG 1966 MAL NEO LYMPH-INTRAPELV 1968 MAL NEO LYMPH NODE-MULT 1969 MAL NEO LYMPH NODE NOS 1970 SECONDARY MALIG NEO LUNG 1971 SEC MAL NEO MEDIASTINUM 1972 SECOND MALIG NEO PLEURA 1973 SEC MALIG NEO RESP NEC 1974 SEC MALIG NEO SM BOWEL 1975 SEC MALIG NEO LG BOWEL 1976 SEC MAL NEO PERITONEUM 1977 SECOND MALIG NEO LIVER 1978 SEC MAL NEO GI NEC 1980 SECOND MALIG NEO KIDNEY 1981 SEC MALIG NEO URIN NEC 1982 SECONDARY MALIG NEO SKIN 1983 SEC MAL NEO BRAIN/SPINE 1984 SEC MALIG NEO NERVE NEC 1985 SECONDARY MALIG NEO BONE 1986 SECOND MALIG NEO OVARY 1987 SECOND MALIG NEO ADRENAL 19881 SECOND MALIG NEO BREAST 19882 SECOND MALIG NEO GENITAL 19889 SECONDARY MALIG NEO NEC 1990 MALIG NEO DISSEMINATED 1991 MALIGNANT NEOPLASM NOS 1992 MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN 20000 RETCLSRC UNSP XTRNDL ORG 20001 RETICULOSARCOMA HEAD 20002 RETICULOSARCOMA THORAX 20003 RETICULOSARCOMA ABDOM 20004 RETICULOSARCOMA AXILLA 20005 RETICULOSARCOMA INGUIN 20006 RETICULOSARCOMA PELVIC May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 23

20007 RETICULOSARCOMA SPLEEN 20008 RETICULOSARCOMA MULT 20010 LYMPHSRC UNSP XTRNDL ORG 20011 LYMPHOSARCOMA HEAD 20012 LYMPHOSARCOMA THORAX 20013 LYMPHOSARCOMA ABDOM 20014 LYMPHOSARCOMA AXILLA 20015 LYMPHOSARCOMA INGUIN 20016 LYMPHOSARCOMA PELVIC 20017 LYMPHOSARCOMA SPLEEN 20018 LYMPHOSARCOMA MULT 20020 BRKT TMR UNSP XTRNDL ORG 20021 BURKITT'S TUMOR HEAD 20022 BURKITT'S TUMOR THORAX 20023 BURKITT'S TUMOR ABDOM 20024 BURKITT'S TUMOR AXILLA 20025 BURKITT'S TUMOR INGUIN 20026 BURKITT'S TUMOR PELVIC 20027 BURKITT'S TUMOR SPLEEN 20028 BURKITT'S TUMOR MULT 20030 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20031 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20032 MARGINAL ZONE LYMPHOMA, INTRATHORACIC LYMPH NODES 20033 MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES 20034 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20035 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 20036 MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES 20037 MARGINAL ZONE LYMPHOMA, SPLEEN 20038 MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20040 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20041 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20042 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 20043 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 20044 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20045 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 24

20046 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 20047 MANTLE CELL LYMPHOMA, SPLEEN 20048 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20050 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20051 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20052 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES 20053 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES 20054 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20055 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 20056 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES 20057 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN 20058 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20060 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20061 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20062 ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 20063 ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 20064 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20065 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 20066 ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 20067 ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN 20068 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20070 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20071 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20072 LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 20073 LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 20074 LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20075 LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 25

20076 LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 20077 LARGE CELL LYMPHOMA, SPLEEN 20078 LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20080 OTH VARN UNSP XTRNDL ORG 20081 MIXED LYMPHOSARC HEAD 20082 MIXED LYMPHOSARC THORAX 20083 MIXED LYMPHOSARC ABDOM 20084 MIXED LYMPHOSARC AXILLA 20085 MIXED LYMPHOSARC INGUIN 20086 MIXED LYMPHOSARC PELVIC 20087 MIXED LYMPHOSARC SPLEEN 20088 MIXED LYMPHOSARC MULT 20100 HDGK PRG UNSP XTRNDL ORG 20101 HODGKINS PARAGRAN HEAD 20102 HODGKINS PARAGRAN THORAX 20103 HODGKINS PARAGRAN ABDOM 20104 HODGKINS PARAGRAN AXILLA 20105 HODGKINS PARAGRAN INGUIN 20106 HODGKINS PARAGRAN PELVIC 20107 HODGKINS PARAGRAN SPLEEN 20108 HODGKINS PARAGRAN MULT 20110 HDGK GRN UNSP XTRNDL ORG 20111 HODGKINS GRANULOM HEAD 20112 HODGKINS GRANULOM THORAX 20113 HODGKINS GRANULOM ABDOM 20114 HODGKINS GRANULOM AXILLA 20115 HODGKINS GRANULOM INGUIN 20116 HODGKINS GRANULOM PELVIC 20117 HODGKINS GRANULOM SPLEEN 20118 HODGKINS GRANULOM MULT 20120 HDGK SRC UNSP XTRNDL ORG 20121 HODGKINS SARCOMA HEAD 20122 HODGKINS SARCOMA THORAX 20123 HODGKINS SARCOMA ABDOM 20124 HODGKINS SARCOMA AXILLA 20125 HODGKINS SARCOMA INGUIN 20126 HODGKINS SARCOMA PELVIC 20127 HODGKINS SARCOMA SPLEEN 20128 HODGKINS SARCOMA MULT 20140 LYM-HST UNSP XTRNDL ORGN 20141 HODG LYMPH-HISTIO HEAD May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 26

20142 HODG LYMPH-HISTIO THORAX 20143 HODG LYMPH-HISTIO ABDOM 20144 HODG LYMPH-HISTIO AXILLA 20145 HODG LYMPH-HISTIO INGUIN 20146 HODG LYMPH-HISTIO PELVIC 20147 HODG LYMPH-HISTIO SPLEEN 20148 HODG LYMPH-HISTIO MULT 20150 NDR SCLR UNSP XTRNDL ORG 20151 HODG NODUL SCLERO HEAD 20152 HODG NODUL SCLERO THORAX 20153 HODG NODUL SCLERO ABDOM 20154 HODG NODUL SCLERO AXILLA 20155 HODG NODUL SCLERO INGUIN 20156 HODG NODUL SCLERO PELVIC 20157 HODG NODUL SCLERO SPLEEN 20158 HODG NODUL SCLERO MULT 20160 MXD CELR UNSP XTRNDL ORG 20161 HODGKINS MIX CELL HEAD 20162 HODGKINS MIX CELL THORAX 20163 HODGKINS MIX CELL ABDOM 20164 HODGKINS MIX CELL AXILLA 20165 HODGKINS MIX CELL INGUIN 20166 HODGKINS MIX CELL PELVIC 20167 HODGKINS MIX CELL SPLEEN 20168 HODGKINS MIX CELL MULT 20170 LYM DPLT UNSP XTRNDL ORG 20171 HODG LYMPH DEPLET HEAD 20172 HODG LYMPH DEPLET THORAX 20173 HODG LYMPH DEPLET ABDOM 20174 HODG LYMPH DEPLET AXILLA 20175 HODG LYMPH DEPLET INGUIN 20176 HODG LYMPH DEPLET PELVIC 20177 HODG LYMPH DEPLET SPLEEN 20178 HODG LYMPH DEPLET MULT 20190 HDGK DIS UNSP XTRNDL ORG 20191 HODGKINS DIS NOS HEAD 20192 HODGKINS DIS NOS THORAX 20193 HODGKINS DIS NOS ABDOM 20194 HODGKINS DIS NOS AXILLA 20195 HODGKINS DIS NOS INGUIN 20196 HODGKINS DIS NOS PELVIC May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 27

20197 HODGKINS DIS NOS SPLEEN 20198 HODGKINS DIS NOS MULT 20200 NDLR LYM UNSP XTRNDL ORG 20201 NODULAR LYMPHOMA HEAD 20202 NODULAR LYMPHOMA THORAX 20203 NODULAR LYMPHOMA ABDOM 20204 NODULAR LYMPHOMA AXILLA 20205 NODULAR LYMPHOMA INGUIN 20206 NODULAR LYMPHOMA PELVIC 20207 NODULAR LYMPHOMA SPLEEN 20208 NODULAR LYMPHOMA MULT 20210 MYCS FNG UNSP XTRNDL ORG 20211 MYCOSIS FUNGOIDES HEAD 20212 MYCOSIS FUNGOIDES THORAX 20213 MYCOSIS FUNGOIDES ABDOM 20214 MYCOSIS FUNGOIDES AXILLA 20215 MYCOSIS FUNGOIDES INGUIN 20216 MYCOSIS FUNGOIDES PELVIC 20217 MYCOSIS FUNGOIDES SPLEEN 20218 MYCOSIS FUNGOIDES MULT 20220 SZRY DIS UNSP XTRNDL ORG 20221 SEZARY'S DISEASE HEAD 20222 SEZARY'S DISEASE THORAX 20223 SEZARY'S DISEASE ABDOM 20224 SEZARY'S DISEASE AXILLA 20225 SEZARY'S DISEASE INGUIN 20226 SEZARY'S DISEASE PELVIC 20227 SEZARY'S DISEASE SPLEEN 20228 SEZARY'S DISEASE MULT 20230 MLG HIST UNSP XTRNDL ORG 20231 MAL HISTIOCYTOSIS HEAD 20232 MAL HISTIOCYTOSIS THORAX 20233 MAL HISTIOCYTOSIS ABDOM 20234 MAL HISTIOCYTOSIS AXILLA 20235 MAL HISTIOCYTOSIS INGUIN 20236 MAL HISTIOCYTOSIS PELVIC 20237 MAL HISTIOCYTOSIS SPLEEN 20238 MAL HISTIOCYTOSIS MULT 20240 LK RTCTL UNSP XTRNDL ORG 20241 HAIRY-CELL LEUKEM HEAD 20242 HAIRY-CELL LEUKEM THORAX May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 28

20243 HAIRY-CELL LEUKEM ABDOM 20244 HAIRY-CELL LEUKEM AXILLA 20245 HAIRY-CELL LEUKEM INGUIN 20246 HAIRY-CELL LEUKEM PELVIC 20247 HAIRY-CELL LEUKEM SPLEEN 20248 HAIRY-CELL LEUKEM MULT 20250 LTR-SIWE UNSP XTRNDL ORG 20251 LETTERER-SIWE DIS HEAD 20252 LETTERER-SIWE DIS THORAX 20253 LETTERER-SIWE DIS ABDOM 20254 LETTERER-SIWE DIS AXILLA 20255 LETTERER-SIWE DIS INGUIN 20256 LETTERER-SIWE DIS PELVIC 20257 LETTERER-SIWE DIS SPLEEN 20258 LETTERER-SIWE DIS MULT 20260 MLG MAST UNSP XTRNDL ORG 20261 MAL MASTOCYTOSIS HEAD 20262 MAL MASTOCYTOSIS THORAX 20263 MAL MASTOCYTOSIS ABDOM 20264 MAL MASTOCYTOSIS AXILLA 20265 MAL MASTOCYTOSIS INGUIN 20266 MAL MASTOCYTOSIS PELVIC 20267 MAL MASTOCYTOSIS SPLEEN 20268 MAL MASTOCYTOSIS MULT 20270 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 20271 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 20272 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 20273 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 20274 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 20275 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 20276 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 20277 PERIPHERAL T CELL LYMPHOMA, SPLEEN 20278 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 20280 OTH LYMP UNSP XTRNDL ORG 20281 LYMPHOMAS NEC HEAD 20282 LYMPHOMAS NEC THORAX 20283 LYMPHOMAS NEC ABDOM 20284 LYMPHOMAS NEC AXILLA May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 29

20285 LYMPHOMAS NEC INGUIN 20286 LYMPHOMAS NEC PELVIC 20287 LYMPHOMAS NEC SPLEEN 20288 LYMPHOMAS NEC MULT 20290 UNSP LYM UNSP XTRNDL ORG 20291 LYMPHOID MAL NEC HEAD 20292 LYMPHOID MAL NEC THORAX 20293 LYMPHOID MAL NEC ABDOM 20294 LYMPHOID MAL NEC AXILLA 20295 LYMPHOID MAL NEC INGUIN 20296 LYMPHOID MAL NEC PELVIC 20297 LYMPHOID MAL NEC SPLEEN 20298 LYMPHOID MAL NEC MULT 20300 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20301 MULT MYELM W REMISSION 20302 MULTIPLE MYELOMA, IN RELAPSE 20310 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20311 PLSM CELL LEUK W RMSON 20312 PLASMA CELL LEUKEMIA, IN RELAPSE 20380 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20381 OTH IMNPRFL NPL W RMSN 20382 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE 20400 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20401 ACT LYM LEUK W RMSION 20402 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE 20410 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20411 CHR LYM LEUK W RMSION 20412 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE 20420 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20421 SBAC LYM LEUK W RMSION 20422 SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE 20480 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20481 OTH LYM LEUK W RMSION 20482 OTHER LYMPHOID LEUKEMIA, IN RELAPSE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 30

20490 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20491 UNS LYM LEUK W RMSION 20492 UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE 20500 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20501 ACT MYL LEUK W RMSION 20502 ACUTE MYELOID LEUKEMIA, IN RELAPSE 20510 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20511 CHR MYL LEUK W RMSION 20512 CHRONIC MYELOID LEUKEMIA, IN RELAPSE 20520 SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20521 SBAC MYL LEUK W RMSION 20522 SUBACUTE MYELOID LEUKEMIA, IN RELAPSE 20530 MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20531 MYL SRCOMA W RMSION 20532 MYELOID SARCOMA, IN RELAPSE 20580 OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20581 OTH MYL LEUK W RMSION 20582 OTHER MYELOID LEUKEMIA, IN RELAPSE 20590 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20591 UNS MYL LEUK W RMSION 20592 UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE 20600 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20601 ACT MONO LEUK W RMSION 20602 ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 20610 CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20611 CHR MONO LEUK W RMSION 20612 CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE 20620 SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20621 SBAC MONO LEUK W RMSION 20622 SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 20680 OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20681 OTH MONO LEUK W RMSION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 31

20682 OTHER MONOCYTIC LEUKEMIA, IN RELAPSE 20690 UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20691 UNS MONO LEUK W RMSION 20692 UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE 20700 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20701 ACT ERTH/ERYLK W RMSON 20702 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE 20710 CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20711 CHR ERYTHRM W REMISION 20712 CHRONIC ERYTHREMIA, IN RELAPSE 20720 MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20721 MGKRYCYT LEUK W RMSION 20722 MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE 20780 OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20781 OTH SPF LEUK W REMSION 20782 OTHER SPECIFIED LEUKEMIA, IN RELAPSE 20800 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20801 ACT LEUK UNS CL W RMSON 20802 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 20810 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20811 CHR LEUK UNS CL W RMSON 20812 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 20820 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20821 SBAC LEUK UNS CL W RMSON 20822 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 20880 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20881 OTH LEUK UNS CL W RMSON 20882 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 20890 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 20891 LEUKEMIA NOS W REMISSION ICD-10 Code C000 C001 Description MALIGNANT NEOPLASM OF EXTERNAL UPPER LIP MALIGNANT NEOPLASM OF EXTERNAL LOWER LIP May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 32

C002 C003 C004 C005 C006 C008 C009 C01 C020 C021 C022 C023 C024 C028 C029 C030 C031 C039 C040 C041 C048 C049 C050 C051 C052 C058 C059 C060 C061 C062 C0680 C0689 C069 C07 C080 C081 C089 C090 MALIGNANT NEOPLASM OF EXTERNAL LIP, UNSPECIFIED MALIGNANT NEOPLASM OF UPPER LIP, INNER ASPECT MALIGNANT NEOPLASM OF LOWER LIP, INNER ASPECT MALIGNANT NEOPLASM OF LIP, UNSPECIFIED, INNER ASPECT MALIGNANT NEOPLASM OF COMMISSURE OF LIP, UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LIP MALIGNANT NEOPLASM OF LIP, UNSPECIFIED MALIGNANT NEOPLASM OF BASE OF TONGUE MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF BORDER OF TONGUE MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE, PART UNSPECIFIED MALIGNANT NEOPLASM OF LINGUAL TONSIL MALIGNANT NEOPLASM OF OVERLAPPING SITES OF TONGUE MALIGNANT NEOPLASM OF TONGUE, UNSPECIFIED MALIGNANT NEOPLASM OF UPPER GUM MALIGNANT NEOPLASM OF LOWER GUM MALIGNANT NEOPLASM OF GUM, UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR FLOOR OF MOUTH MALIGNANT NEOPLASM OF LATERAL FLOOR OF MOUTH MALIGNANT NEOPLASM OF OVERLAPPING SITES OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF FLOOR OF MOUTH, UNSPECIFIED MALIGNANT NEOPLASM OF HARD PALATE MALIGNANT NEOPLASM OF SOFT PALATE MALIGNANT NEOPLASM OF UVULA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PALATE MALIGNANT NEOPLASM OF PALATE, UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH MALIGNANT NEOPLASM OF RETROMOLAR AREA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED PARTS OF MOUTH MALIGNANT NEOPLASM OF OVERLAPPING SITES OF OTHER PARTS OF MOUTH MALIGNANT NEOPLASM OF MOUTH, UNSPECIFIED MALIGNANT NEOPLASM OF PAROTID GLAND MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND MALIGNANT NEOPLASM OF SUBLINGUAL GLAND MALIGNANT NEOPLASM OF MAJOR SALIVARY GLAND, UNSPECIFIED MALIGNANT NEOPLASM OF TONSILLAR FOSSA May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 33

C091 C098 C099 C100 C101 C102 C103 C104 C108 C109 C110 C111 C112 C113 C118 C119 C12 C130 C131 C132 C138 C139 C140 C142 C148 C153 C154 C155 C158 C159 C160 C161 C162 C163 C164 C165 C166 MALIGNANT NEOPLASM OF TONSILLAR PILLAR (ANTERIOR) (POSTERIOR) MALIGNANT NEOPLASM OF OVERLAPPING SITES OF TONSIL MALIGNANT NEOPLASM OF TONSIL, UNSPECIFIED MALIGNANT NEOPLASM OF VALLECULA MALIGNANT NEOPLASM OF ANTERIOR SURFACE OF EPIGLOTTIS MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX MALIGNANT NEOPLASM OF BRANCHIAL CLEFT MALIGNANT NEOPLASM OF OVERLAPPING SITES OF OROPHARYNX MALIGNANT NEOPLASM OF OROPHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF OVERLAPPING SITES OF NASOPHARYNX MALIGNANT NEOPLASM OF NASOPHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF PYRIFORM SINUS MALIGNANT NEOPLASM OF POSTCRICOID REGION MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD, HYPOPHARYNGEAL ASPECT MALIGNANT NEOPLASM OF POSTERIOR WALL OF HYPOPHARYNX MALIGNANT NEOPLASM OF OVERLAPPING SITES OF HYPOPHARYNX MALIGNANT NEOPLASM OF HYPOPHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF PHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF WALDEYER'S RING MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LIP, ORAL CAVITY AND PHARYNX MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF ESOPHAGUS MALIGNANT NEOPLASM OF ESOPHAGUS, UNSPECIFIED MALIGNANT NEOPLASM OF CARDIA MALIGNANT NEOPLASM OF FUNDUS OF STOMACH MALIGNANT NEOPLASM OF BODY OF STOMACH MALIGNANT NEOPLASM OF PYLORIC ANTRUM MALIGNANT NEOPLASM OF PYLORUS MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH, UNSPECIFIED MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH, UNSPECIFIED May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 34

C168 C169 C170 C171 C172 C173 C178 C179 C180 C181 C182 C183 C184 C185 C186 C187 C188 C189 C19 C20 C210 C211 C212 C218 C220 C221 C222 C223 C224 C227 C228 C229 C23 C240 C241 C248 C249 C250 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF STOMACH MALIGNANT NEOPLASM OF STOMACH, UNSPECIFIED MALIGNANT NEOPLASM OF DUODENUM MALIGNANT NEOPLASM OF JEJUNUM MALIGNANT NEOPLASM OF ILEUM MECKEL'S DIVERTICULUM, MALIGNANT MALIGNANT NEOPLASM OF OVERLAPPING SITES OF SMALL INTESTINE MALIGNANT NEOPLASM OF SMALL INTESTINE, UNSPECIFIED MALIGNANT NEOPLASM OF CECUM MALIGNANT NEOPLASM OF APPENDIX MALIGNANT NEOPLASM OF ASCENDING COLON MALIGNANT NEOPLASM OF HEPATIC FLEXURE MALIGNANT NEOPLASM OF TRANSVERSE COLON MALIGNANT NEOPLASM OF SPLENIC FLEXURE MALIGNANT NEOPLASM OF DESCENDING COLON MALIGNANT NEOPLASM OF SIGMOID COLON MALIGNANT NEOPLASM OF OVERLAPPING SITES OF COLON MALIGNANT NEOPLASM OF COLON, UNSPECIFIED MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF ANUS, UNSPECIFIED MALIGNANT NEOPLASM OF ANAL CANAL MALIGNANT NEOPLASM OF CLOACOGENIC ZONE MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RECTUM, ANUS AND ANAL CANAL LIVER CELL CARCINOMA INTRAHEPATIC BILE DUCT CARCINOMA HEPATOBLASTOMA ANGIOSARCOMA OF LIVER OTHER SARCOMAS OF LIVER OTHER SPECIFIED CARCINOMAS OF LIVER MALIGNANT NEOPLASM OF LIVER, PRIMARY, UNSPECIFIED AS TO TYPE MALIGNANT NEOPLASM OF LIVER, NOT SPECIFIED AS PRIMARY OR SECONDARY MALIGNANT NEOPLASM OF GALLBLADDER MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCT MALIGNANT NEOPLASM OF AMPULLA OF VATER MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BILIARY TRACT MALIGNANT NEOPLASM OF BILIARY TRACT, UNSPECIFIED MALIGNANT NEOPLASM OF HEAD OF PANCREAS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 35

C251 C252 C253 C254 C257 C258 C259 C260 C261 C269 C300 C301 C310 C311 C312 C313 C318 C319 C320 C321 C322 C323 C328 C329 C33 C3400 C3401 C3402 C3410 C3411 C3412 C342 C3430 C3431 C3432 C3480 MALIGNANT NEOPLASM OF BODY OF PANCREAS MALIGNANT NEOPLASM OF TAIL OF PANCREAS MALIGNANT NEOPLASM OF PANCREATIC DUCT MALIGNANT NEOPLASM OF ENDOCRINE PANCREAS MALIGNANT NEOPLASM OF OTHER PARTS OF PANCREAS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PANCREAS MALIGNANT NEOPLASM OF PANCREAS, UNSPECIFIED MALIGNANT NEOPLASM OF INTESTINAL TRACT, PART UNSPECIFIED MALIGNANT NEOPLASM OF SPLEEN MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE SYSTEM MALIGNANT NEOPLASM OF NASAL CAVITY MALIGNANT NEOPLASM OF MIDDLE EAR MALIGNANT NEOPLASM OF MAXILLARY SINUS MALIGNANT NEOPLASM OF ETHMOIDAL SINUS MALIGNANT NEOPLASM OF FRONTAL SINUS MALIGNANT NEOPLASM OF SPHENOID SINUS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF ACCESSORY SINUSES MALIGNANT NEOPLASM OF ACCESSORY SINUS, UNSPECIFIED MALIGNANT NEOPLASM OF GLOTTIS MALIGNANT NEOPLASM OF SUPRAGLOTTIS MALIGNANT NEOPLASM OF SUBGLOTTIS MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGE MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LARYNX MALIGNANT NEOPLASM OF LARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF TRACHEA MALIGNANT NEOPLASM OF UNSPECIFIED MAIN BRONCHUS MALIGNANT NEOPLASM OF RIGHT MAIN BRONCHUS MALIGNANT NEOPLASM OF LEFT MAIN BRONCHUS MALIGNANT NEOPLASM OF UPPER LOBE, UNSPECIFIED BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UPPER LOBE, RIGHT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF MIDDLE LOBE, BRONCHUS OR LUNG MALIGNANT NEOPLASM OF LOWER LOBE, UNSPECIFIED BRONCHUS OR LUNG MALIGNANT NEOPLASM OF LOWER LOBE, RIGHT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF LOWER LOBE, LEFT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED BRONCHUS AND LUNG May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 36

C3481 C3482 C3490 C3491 C3492 C37 C380 C381 C382 C383 C384 C388 C390 C399 C4000 C4001 C4002 C4010 C4011 C4012 C4020 C4021 C4022 C4030 C4031 C4032 C4080 C4081 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RIGHT BRONCHUS AND LUNG MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LEFT BRONCHUS AND LUNG MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UNSPECIFIED PART OF RIGHT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UNSPECIFIED PART OF LEFT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF THYMUS MALIGNANT NEOPLASM OF HEART MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF MEDIASTINUM, PART UNSPECIFIED MALIGNANT NEOPLASM OF PLEURA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF HEART, MEDIASTINUM AND PLEURA MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT, PART UNSPECIFIED MALIGNANT NEOPLASM OF LOWER RESPIRATORY TRACT, PART UNSPECIFIED MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UNSPECIFIED UPPER LIMB MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF RIGHT UPPER LIMB MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF LEFT UPPER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF UNSPECIFIED UPPER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF RIGHT UPPER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF LEFT UPPER LIMB MALIGNANT NEOPLASM OF LONG BONES OF UNSPECIFIED LOWER LIMB MALIGNANT NEOPLASM OF LONG BONES OF RIGHT LOWER LIMB MALIGNANT NEOPLASM OF LONG BONES OF LEFT LOWER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF UNSPECIFIED LOWER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF RIGHT LOWER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF LEFT LOWER LIMB MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BONE AND ARTICULAR CARTILAGE OF UNSPECIFIED LIMB MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BONE AND ARTICULAR CARTILAGE OF RIGHT LIMB May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 37

C4082 C4090 C4091 C4092 C410 C411 C412 C413 C414 C419 C430 C4310 C4311 C4312 C4320 C4321 C4322 C4330 C4331 C4339 C434 C4351 C4352 C4359 C4360 C4361 C4362 C4370 C4371 C4372 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BONE AND ARTICULAR CARTILAGE OF LEFT LIMB MALIGNANT NEOPLASM OF UNSPECIFIED BONES AND ARTICULAR CARTILAGE OF UNSPECIFIED LIMB MALIGNANT NEOPLASM OF UNSPECIFIED BONES AND ARTICULAR CARTILAGE OF RIGHT LIMB MALIGNANT NEOPLASM OF UNSPECIFIED BONES AND ARTICULAR CARTILAGE OF LEFT LIMB MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE MALIGNANT NEOPLASM OF MANDIBLE MALIGNANT NEOPLASM OF VERTEBRAL COLUMN MALIGNANT NEOPLASM OF RIBS, STERNUM AND CLAVICLE MALIGNANT NEOPLASM OF PELVIC BONES, SACRUM AND COCCYX MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE, UNSPECIFIED MALIGNANT MELANOMA OF LIP MALIGNANT MELANOMA OF UNSPECIFIED EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF RIGHT EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF LEFT EYELID, INCLUDING CANTHUS MALIGNANT MELANOMA OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF RIGHT EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF LEFT EAR AND EXTERNAL AURICULAR CANAL MALIGNANT MELANOMA OF UNSPECIFIED PART OF FACE MALIGNANT MELANOMA OF NOSE MALIGNANT MELANOMA OF OTHER PARTS OF FACE MALIGNANT MELANOMA OF SCALP AND NECK MALIGNANT MELANOMA OF ANAL SKIN MALIGNANT MELANOMA OF SKIN OF BREAST MALIGNANT MELANOMA OF OTHER PART OF TRUNK MALIGNANT MELANOMA OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MALIGNANT MELANOMA OF RIGHT UPPER LIMB, INCLUDING SHOULDER MALIGNANT MELANOMA OF LEFT UPPER LIMB, INCLUDING SHOULDER MALIGNANT MELANOMA OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MALIGNANT MELANOMA OF RIGHT LOWER LIMB, INCLUDING HIP MALIGNANT MELANOMA OF LEFT LOWER LIMB, INCLUDING HIP May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 38

C438 C439 C450 C451 C452 C457 C459 C460 C461 C462 C463 C464 C4650 C4651 C4652 C467 C469 C470 C4710 C4711 C4712 C4720 C4721 C4722 C473 C474 C475 C476 C478 C479 C480 C481 C482 MALIGNANT MELANOMA OF OVERLAPPING SITES OF SKIN MALIGNANT MELANOMA OF SKIN, UNSPECIFIED MESOTHELIOMA OF PLEURA MESOTHELIOMA OF PERITONEUM MESOTHELIOMA OF PERICARDIUM MESOTHELIOMA OF OTHER SITES MESOTHELIOMA, UNSPECIFIED KAPOSI'S SARCOMA OF SKIN KAPOSI'S SARCOMA OF SOFT TISSUE KAPOSI'S SARCOMA OF PALATE KAPOSI'S SARCOMA OF LYMPH NODES KAPOSI'S SARCOMA OF GASTROINTESTINAL SITES KAPOSI'S SARCOMA OF UNSPECIFIED LUNG KAPOSI'S SARCOMA OF RIGHT LUNG KAPOSI'S SARCOMA OF LEFT LUNG KAPOSI'S SARCOMA OF OTHER SITES KAPOSI'S SARCOMA, UNSPECIFIED MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF HEAD, FACE AND NECK MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF RIGHT UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF LEFT UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF RIGHT LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF LEFT LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF THORAX MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF ABDOMEN MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF PELVIS MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF TRUNK, UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PERIPHERAL NERVES AND AUTONOMIC NERVOUS SYSTEM MALIGNANT NEOPLASM OF PERIPHERAL NERVES AND AUTONOMIC NERVOUS SYSTEM, UNSPECIFIED MALIGNANT NEOPLASM OF RETROPERITONEUM MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM MALIGNANT NEOPLASM OF PERITONEUM, UNSPECIFIED May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 39

C488 C490 C4910 C4911 C4912 C4920 C4921 C4922 C493 C494 C495 C496 C498 C499 C50011 C50012 C50019 C50021 C50022 C50029 C50111 C50112 C50119 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RETROPERITONEUM AND PERITONEUM MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF HEAD, FACE AND NECK MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF RIGHT UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF LEFT UPPER LIMB, INCLUDING SHOULDER MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF RIGHT LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF LEFT LOWER LIMB, INCLUDING HIP MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF THORAX MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF ABDOMEN MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF PELVIS MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF TRUNK, UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF CONNECTIVE AND SOFT TISSUE MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, LEFT FEMALE BREAST MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, RIGHT MALE BREAST MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, LEFT MALE BREAST MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF UNSPECIFIED FEMALE BREAST May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 40

C50121 C50122 C50129 C50211 C50212 C50219 C50221 C50222 C50229 C50311 C50312 C50319 C50321 C50322 C50329 C50411 C50412 C50419 C50421 C50422 C50429 C50511 MALIGNANT NEOPLASM OF CENTRAL PORTION OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF LEFT MALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF LEFT MALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF LEFT MALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF LEFT MALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF RIGHT FEMALE BREAST May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 41

C50512 C50519 C50521 C50522 C50529 C50611 C50612 C50619 C50621 C50622 C50629 C50811 C50812 C50819 C50821 C50822 C50829 C50911 C50912 C50919 C50921 C50922 C50929 C510 C511 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF LEFT MALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF LEFT MALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LEFT MALE BREAST MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF RIGHT FEMALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF LEFT FEMALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF UNSPECIFIED FEMALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF RIGHT MALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF LEFT MALE BREAST MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF UNSPECIFIED MALE BREAST MALIGNANT NEOPLASM OF LABIUM MAJUS MALIGNANT NEOPLASM OF LABIUM MINUS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 42

C512 C518 C519 C52 C530 C531 C538 C539 C540 C541 C542 C543 C548 C549 C55 C561 C562 C569 C5700 C5701 C5702 C5710 C5711 C5712 C5720 C5721 C5722 C573 C574 C577 C578 C579 C58 C600 C601 C602 C608 C609 C61 MALIGNANT NEOPLASM OF CLITORIS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF VULVA MALIGNANT NEOPLASM OF VULVA, UNSPECIFIED MALIGNANT NEOPLASM OF VAGINA MALIGNANT NEOPLASM OF ENDOCERVIX MALIGNANT NEOPLASM OF EXOCERVIX MALIGNANT NEOPLASM OF OVERLAPPING SITES OF CERVIX UTERI MALIGNANT NEOPLASM OF CERVIX UTERI, UNSPECIFIED MALIGNANT NEOPLASM OF ISTHMUS UTERI MALIGNANT NEOPLASM OF ENDOMETRIUM MALIGNANT NEOPLASM OF MYOMETRIUM MALIGNANT NEOPLASM OF FUNDUS UTERI MALIGNANT NEOPLASM OF OVERLAPPING SITES OF CORPUS UTERI MALIGNANT NEOPLASM OF CORPUS UTERI, UNSPECIFIED MALIGNANT NEOPLASM OF UTERUS, PART UNSPECIFIED MALIGNANT NEOPLASM OF RIGHT OVARY MALIGNANT NEOPLASM OF LEFT OVARY MALIGNANT NEOPLASM OF UNSPECIFIED OVARY MALIGNANT NEOPLASM OF UNSPECIFIED FALLOPIAN TUBE MALIGNANT NEOPLASM OF RIGHT FALLOPIAN TUBE MALIGNANT NEOPLASM OF LEFT FALLOPIAN TUBE MALIGNANT NEOPLASM OF UNSPECIFIED BROAD LIGAMENT MALIGNANT NEOPLASM OF RIGHT BROAD LIGAMENT MALIGNANT NEOPLASM OF LEFT BROAD LIGAMENT MALIGNANT NEOPLASM OF UNSPECIFIED ROUND LIGAMENT MALIGNANT NEOPLASM OF RIGHT ROUND LIGAMENT MALIGNANT NEOPLASM OF LEFT ROUND LIGAMENT MALIGNANT NEOPLASM OF PARAMETRIUM MALIGNANT NEOPLASM OF UTERINE ADNEXA, UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED FEMALE GENITAL ORGANS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF FEMALE GENITAL ORGANS MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN, UNSPECIFIED MALIGNANT NEOPLASM OF PLACENTA MALIGNANT NEOPLASM OF PREPUCE MALIGNANT NEOPLASM OF GLANS PENIS MALIGNANT NEOPLASM OF BODY OF PENIS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PENIS MALIGNANT NEOPLASM OF PENIS, UNSPECIFIED MALIGNANT NEOPLASM OF PROSTATE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 43

C6200 C6201 C6202 C6210 C6211 C6212 C6290 C6291 C6292 C6300 C6301 C6302 C6310 C6311 C6312 C632 C637 C638 C639 C641 C642 C649 C651 C652 C659 C661 C662 C669 C670 C671 C672 C673 C674 C675 C676 C677 MALIGNANT NEOPLASM OF UNSPECIFIED UNDESCENDED TESTIS MALIGNANT NEOPLASM OF UNDESCENDED RIGHT TESTIS MALIGNANT NEOPLASM OF UNDESCENDED LEFT TESTIS MALIGNANT NEOPLASM OF UNSPECIFIED DESCENDED TESTIS MALIGNANT NEOPLASM OF DESCENDED RIGHT TESTIS MALIGNANT NEOPLASM OF DESCENDED LEFT TESTIS MALIGNANT NEOPLASM OF UNSPECIFIED TESTIS, UNSPECIFIED WHETHER DESCENDED OR UNDESCENDED MALIGNANT NEOPLASM OF RIGHT TESTIS, UNSPECIFIED WHETHER DESCENDED OR UNDESCENDED MALIGNANT NEOPLASM OF LEFT TESTIS, UNSPECIFIED WHETHER DESCENDED OR UNDESCENDED MALIGNANT NEOPLASM OF UNSPECIFIED EPIDIDYMIS MALIGNANT NEOPLASM OF RIGHT EPIDIDYMIS MALIGNANT NEOPLASM OF LEFT EPIDIDYMIS MALIGNANT NEOPLASM OF UNSPECIFIED SPERMATIC CORD MALIGNANT NEOPLASM OF RIGHT SPERMATIC CORD MALIGNANT NEOPLASM OF LEFT SPERMATIC CORD MALIGNANT NEOPLASM OF SCROTUM MALIGNANT NEOPLASM OF OTHER SPECIFIED MALE GENITAL ORGANS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF MALE GENITAL ORGANS MALIGNANT NEOPLASM OF MALE GENITAL ORGAN, UNSPECIFIED MALIGNANT NEOPLASM OF RIGHT KIDNEY, EXCEPT RENAL PELVIS MALIGNANT NEOPLASM OF LEFT KIDNEY, EXCEPT RENAL PELVIS MALIGNANT NEOPLASM OF UNSPECIFIED KIDNEY, EXCEPT RENAL PELVIS MALIGNANT NEOPLASM OF RIGHT RENAL PELVIS MALIGNANT NEOPLASM OF LEFT RENAL PELVIS MALIGNANT NEOPLASM OF UNSPECIFIED RENAL PELVIS MALIGNANT NEOPLASM OF RIGHT URETER MALIGNANT NEOPLASM OF LEFT URETER MALIGNANT NEOPLASM OF UNSPECIFIED URETER MALIGNANT NEOPLASM OF TRIGONE OF BLADDER MALIGNANT NEOPLASM OF DOME OF BLADDER MALIGNANT NEOPLASM OF LATERAL WALL OF BLADDER MALIGNANT NEOPLASM OF ANTERIOR WALL OF BLADDER MALIGNANT NEOPLASM OF POSTERIOR WALL OF BLADDER MALIGNANT NEOPLASM OF BLADDER NECK MALIGNANT NEOPLASM OF URETERIC ORIFICE MALIGNANT NEOPLASM OF URACHUS May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 44

C678 C679 C680 C681 C688 C689 C6900 C6901 C6902 C6910 C6911 C6912 C6920 C6921 C6922 C6930 C6931 C6932 C6940 C6941 C6942 C6950 C6951 C6952 C6960 C6961 C6962 C6980 C6981 C6982 C6990 C6991 C6992 C700 C701 C709 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BLADDER MALIGNANT NEOPLASM OF BLADDER, UNSPECIFIED MALIGNANT NEOPLASM OF URETHRA MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF URINARY ORGANS MALIGNANT NEOPLASM OF URINARY ORGAN, UNSPECIFIED MALIGNANT NEOPLASM OF UNSPECIFIED CONJUNCTIVA MALIGNANT NEOPLASM OF RIGHT CONJUNCTIVA MALIGNANT NEOPLASM OF LEFT CONJUNCTIVA MALIGNANT NEOPLASM OF UNSPECIFIED CORNEA MALIGNANT NEOPLASM OF RIGHT CORNEA MALIGNANT NEOPLASM OF LEFT CORNEA MALIGNANT NEOPLASM OF UNSPECIFIED RETINA MALIGNANT NEOPLASM OF RIGHT RETINA MALIGNANT NEOPLASM OF LEFT RETINA MALIGNANT NEOPLASM OF UNSPECIFIED CHOROID MALIGNANT NEOPLASM OF RIGHT CHOROID MALIGNANT NEOPLASM OF LEFT CHOROID MALIGNANT NEOPLASM OF UNSPECIFIED CILIARY BODY MALIGNANT NEOPLASM OF RIGHT CILIARY BODY MALIGNANT NEOPLASM OF LEFT CILIARY BODY MALIGNANT NEOPLASM OF UNSPECIFIED LACRIMAL GLAND AND DUCT MALIGNANT NEOPLASM OF RIGHT LACRIMAL GLAND AND DUCT MALIGNANT NEOPLASM OF LEFT LACRIMAL GLAND AND DUCT MALIGNANT NEOPLASM OF UNSPECIFIED ORBIT MALIGNANT NEOPLASM OF RIGHT ORBIT MALIGNANT NEOPLASM OF LEFT ORBIT MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED EYE AND ADNEXA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RIGHT EYE AND ADNEXA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LEFT EYE AND ADNEXA MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF UNSPECIFIED EYE MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF RIGHT EYE MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF LEFT EYE MALIGNANT NEOPLASM OF CEREBRAL MENINGES MALIGNANT NEOPLASM OF SPINAL MENINGES MALIGNANT NEOPLASM OF MENINGES, UNSPECIFIED May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 45

C710 C711 C712 C713 C714 C715 C716 C717 C718 C719 C720 C721 C7220 C7221 C7222 C7230 C7231 C7232 C7240 C7241 C7242 C7250 C7259 C729 C73 C7400 C7401 C7402 C7410 C7411 C7412 C7490 C7491 C7492 C750 MALIGNANT NEOPLASM OF CEREBRUM, EXCEPT LOBES AND VENTRICLES MALIGNANT NEOPLASM OF FRONTAL LOBE MALIGNANT NEOPLASM OF TEMPORAL LOBE MALIGNANT NEOPLASM OF PARIETAL LOBE MALIGNANT NEOPLASM OF OCCIPITAL LOBE MALIGNANT NEOPLASM OF CEREBRAL VENTRICLE MALIGNANT NEOPLASM OF CEREBELLUM MALIGNANT NEOPLASM OF BRAIN STEM MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BRAIN MALIGNANT NEOPLASM OF BRAIN, UNSPECIFIED MALIGNANT NEOPLASM OF SPINAL CORD MALIGNANT NEOPLASM OF CAUDA EQUINA MALIGNANT NEOPLASM OF UNSPECIFIED OLFACTORY NERVE MALIGNANT NEOPLASM OF RIGHT OLFACTORY NERVE MALIGNANT NEOPLASM OF LEFT OLFACTORY NERVE MALIGNANT NEOPLASM OF UNSPECIFIED OPTIC NERVE MALIGNANT NEOPLASM OF RIGHT OPTIC NERVE MALIGNANT NEOPLASM OF LEFT OPTIC NERVE MALIGNANT NEOPLASM OF UNSPECIFIED ACOUSTIC NERVE MALIGNANT NEOPLASM OF RIGHT ACOUSTIC NERVE MALIGNANT NEOPLASM OF LEFT ACOUSTIC NERVE MALIGNANT NEOPLASM OF UNSPECIFIED CRANIAL NERVE MALIGNANT NEOPLASM OF OTHER CRANIAL NERVES MALIGNANT NEOPLASM OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED MALIGNANT NEOPLASM OF THYROID GLAND MALIGNANT NEOPLASM OF CORTEX OF UNSPECIFIED ADRENAL GLAND MALIGNANT NEOPLASM OF CORTEX OF RIGHT ADRENAL GLAND MALIGNANT NEOPLASM OF CORTEX OF LEFT ADRENAL GLAND MALIGNANT NEOPLASM OF MEDULLA OF UNSPECIFIED ADRENAL GLAND MALIGNANT NEOPLASM OF MEDULLA OF RIGHT ADRENAL GLAND MALIGNANT NEOPLASM OF MEDULLA OF LEFT ADRENAL GLAND MALIGNANT NEOPLASM OF UNSPECIFIED PART OF UNSPECIFIED ADRENAL GLAND MALIGNANT NEOPLASM OF UNSPECIFIED PART OF RIGHT ADRENAL GLAND MALIGNANT NEOPLASM OF UNSPECIFIED PART OF LEFT ADRENAL GLAND MALIGNANT NEOPLASM OF PARATHYROID GLAND May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 46

C751 C752 C753 C754 C755 C758 C759 C760 C761 C762 C763 C7640 C7641 C7642 C7650 C7651 C7652 C768 C770 C771 C772 C773 C774 C775 C778 C779 C7800 C7801 C7802 C781 C782 C7830 MALIGNANT NEOPLASM OF PITUITARY GLAND MALIGNANT NEOPLASM OF CRANIOPHARYNGEAL DUCT MALIGNANT NEOPLASM OF PINEAL GLAND MALIGNANT NEOPLASM OF CAROTID BODY MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA MALIGNANT NEOPLASM WITH PLURIGLANDULAR INVOLVEMENT, UNSPECIFIED MALIGNANT NEOPLASM OF ENDOCRINE GLAND, UNSPECIFIED MALIGNANT NEOPLASM OF HEAD, FACE AND NECK MALIGNANT NEOPLASM OF THORAX MALIGNANT NEOPLASM OF ABDOMEN MALIGNANT NEOPLASM OF PELVIS MALIGNANT NEOPLASM OF UNSPECIFIED UPPER LIMB MALIGNANT NEOPLASM OF RIGHT UPPER LIMB MALIGNANT NEOPLASM OF LEFT UPPER LIMB MALIGNANT NEOPLASM OF UNSPECIFIED LOWER LIMB MALIGNANT NEOPLASM OF RIGHT LOWER LIMB MALIGNANT NEOPLASM OF LEFT LOWER LIMB MALIGNANT NEOPLASM OF OTHER SPECIFIED ILL-DEFINED SITES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD, FACE AND NECK SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA- ABDOMINAL LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF AXILLA AND UPPER LIMB LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INGUINAL AND LOWER LIMB LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE REGIONS SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODE, UNSPECIFIED SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED LUNG SECONDARY MALIGNANT NEOPLASM OF RIGHT LUNG SECONDARY MALIGNANT NEOPLASM OF LEFT LUNG SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM SECONDARY MALIGNANT NEOPLASM OF PLEURA SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED RESPIRATORY ORGAN May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 47

C7839 C784 C785 C786 C787 C7880 C7889 C7900 C7901 C7902 C7910 C7911 C7919 C792 C7931 C7932 C7940 C7949 C7951 C7952 C7960 C7961 C7962 C7970 C7971 C7972 C7981 C7982 C7989 C799 C800 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM SECONDARY MALIGNANT NEOPLASM OF LIVER AND INTRAHEPATIC BILE DUCT SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED DIGESTIVE ORGAN SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED KIDNEY AND RENAL PELVIS SECONDARY MALIGNANT NEOPLASM OF RIGHT KIDNEY AND RENAL PELVIS SECONDARY MALIGNANT NEOPLASM OF LEFT KIDNEY AND RENAL PELVIS SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED URINARY ORGANS SECONDARY MALIGNANT NEOPLASM OF BLADDER SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS SECONDARY MALIGNANT NEOPLASM OF SKIN SECONDARY MALIGNANT NEOPLASM OF BRAIN SECONDARY MALIGNANT NEOPLASM OF CEREBRAL MENINGES SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED PART OF NERVOUS SYSTEM SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM SECONDARY MALIGNANT NEOPLASM OF BONE SECONDARY MALIGNANT NEOPLASM OF BONE MARROW SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED OVARY SECONDARY MALIGNANT NEOPLASM OF RIGHT OVARY SECONDARY MALIGNANT NEOPLASM OF LEFT OVARY SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF RIGHT ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF LEFT ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF BREAST SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED SITE DISSEMINATED MALIGNANT NEOPLASM, UNSPECIFIED May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 48

C801 C802 C8100 C8101 C8102 C8103 C8104 C8105 C8106 C8107 C8108 C8109 C8110 C8111 C8112 C8113 C8114 C8115 C8116 C8117 C8118 C8119 C8120 C8121 MALIGNANT (PRIMARY) NEOPLASM, UNSPECIFIED MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANTED ORGAN NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, UNSPECIFIED SITE NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, SPLEEN NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, UNSPECIFIED SITE NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, SPLEEN NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES NODULAR SCLEROSIS CLASSICAL HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, UNSPECIFIED SITE MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 49

C8122 C8123 C8124 C8125 C8126 C8127 C8128 C8129 C8130 C8131 C8132 C8133 C8134 C8135 C8136 C8137 C8138 C8139 C8140 C8141 C8142 C8143 C8144 MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, SPLEEN MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MIXED CELLULARITY CLASSICAL HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, UNSPECIFIED SITE LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, SPLEEN LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LYMPHOCYTE DEPLETED CLASSICAL HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, UNSPECIFIED SITE LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 50

C8145 C8146 C8147 C8148 C8149 C8170 C8171 C8172 C8173 C8174 C8175 C8176 C8177 C8178 C8179 C8190 C8191 C8192 C8193 C8194 C8195 C8196 C8197 C8198 C8199 LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, SPLEEN LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LYMPHOCYTE-RICH CLASSICAL HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES OTHER CLASSICAL HODGKIN LYMPHOMA, UNSPECIFIED SITE OTHER CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK OTHER CLASSICAL HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES OTHER CLASSICAL HODGKIN LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES OTHER CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB OTHER CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER CLASSICAL HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES OTHER CLASSICAL HODGKIN LYMPHOMA, SPLEEN OTHER CLASSICAL HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER CLASSICAL HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES HODGKIN LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK HODGKIN LYMPHOMA, UNSPECIFIED, INTRATHORACIC LYMPH NODES HODGKIN LYMPHOMA, UNSPECIFIED, INTRA-ABDOMINAL LYMPH NODES HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN LYMPHOMA, UNSPECIFIED, INTRAPELVIC LYMPH NODES HODGKIN LYMPHOMA, UNSPECIFIED, SPLEEN HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES HODGKIN LYMPHOMA, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 51

C8200 C8201 C8202 C8203 C8204 C8205 C8206 C8207 C8208 C8209 C8210 C8211 C8212 C8213 C8214 C8215 C8216 C8217 C8218 C8219 C8220 C8221 C8222 C8223 C8224 C8225 C8226 FOLLICULAR LYMPHOMA GRADE I, UNSPECIFIED SITE FOLLICULAR LYMPHOMA GRADE I, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA GRADE I, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE I, INTRA-ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA GRADE I, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA GRADE I, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA GRADE I, INTRAPELVIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE I, SPLEEN FOLLICULAR LYMPHOMA GRADE I, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA GRADE I, EXTRANODAL AND SOLID ORGAN SITES FOLLICULAR LYMPHOMA GRADE II, UNSPECIFIED SITE FOLLICULAR LYMPHOMA GRADE II, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA GRADE II, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE II, INTRA-ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA GRADE II, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA GRADE II, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA GRADE II, INTRAPELVIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE II, SPLEEN FOLLICULAR LYMPHOMA GRADE II, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA GRADE II, EXTRANODAL AND SOLID ORGAN SITES FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, UNSPECIFIED SITE FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, INTRA- ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, INTRAPELVIC LYMPH NODES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 52

C8227 C8228 C8229 C8230 C8231 C8232 C8233 C8234 C8235 C8236 C8237 C8238 C8239 C8240 C8241 C8242 C8243 C8244 C8245 C8246 C8247 C8248 C8249 C8250 C8251 C8252 C8253 FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, SPLEEN FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA GRADE III, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES FOLLICULAR LYMPHOMA GRADE IIIA, UNSPECIFIED SITE FOLLICULAR LYMPHOMA GRADE IIIA, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA GRADE IIIA, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIA, INTRA-ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIA, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA GRADE IIIA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA GRADE IIIA, INTRAPELVIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIA, SPLEEN FOLLICULAR LYMPHOMA GRADE IIIA, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA GRADE IIIA, EXTRANODAL AND SOLID ORGAN SITES FOLLICULAR LYMPHOMA GRADE IIIB, UNSPECIFIED SITE FOLLICULAR LYMPHOMA GRADE IIIB, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA GRADE IIIB, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIB, INTRA-ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIB, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA GRADE IIIB, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA GRADE IIIB, INTRAPELVIC LYMPH NODES FOLLICULAR LYMPHOMA GRADE IIIB, SPLEEN FOLLICULAR LYMPHOMA GRADE IIIB, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA GRADE IIIB, EXTRANODAL AND SOLID ORGAN SITES DIFFUSE FOLLICLE CENTER LYMPHOMA, UNSPECIFIED SITE DIFFUSE FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK DIFFUSE FOLLICLE CENTER LYMPHOMA, INTRATHORACIC LYMPH NODES DIFFUSE FOLLICLE CENTER LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 53

C8254 C8255 C8256 C8257 C8258 C8259 C8260 C8261 C8262 C8263 C8264 C8265 C8266 C8267 C8268 C8269 C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288 DIFFUSE FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB DIFFUSE FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB DIFFUSE FOLLICLE CENTER LYMPHOMA, INTRAPELVIC LYMPH NODES DIFFUSE FOLLICLE CENTER LYMPHOMA, SPLEEN DIFFUSE FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF MULTIPLE SITES DIFFUSE FOLLICLE CENTER LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES CUTANEOUS FOLLICLE CENTER LYMPHOMA, UNSPECIFIED SITE CUTANEOUS FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK CUTANEOUS FOLLICLE CENTER LYMPHOMA, INTRATHORACIC LYMPH NODES CUTANEOUS FOLLICLE CENTER LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES CUTANEOUS FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB CUTANEOUS FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB CUTANEOUS FOLLICLE CENTER LYMPHOMA, INTRAPELVIC LYMPH NODES CUTANEOUS FOLLICLE CENTER LYMPHOMA, SPLEEN CUTANEOUS FOLLICLE CENTER LYMPHOMA, LYMPH NODES OF MULTIPLE SITES CUTANEOUS FOLLICLE CENTER LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES OTHER TYPES OF FOLLICULAR LYMPHOMA, UNSPECIFIED SITE OTHER TYPES OF FOLLICULAR LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK OTHER TYPES OF FOLLICULAR LYMPHOMA, INTRATHORACIC LYMPH NODES OTHER TYPES OF FOLLICULAR LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES OTHER TYPES OF FOLLICULAR LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB OTHER TYPES OF FOLLICULAR LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER TYPES OF FOLLICULAR LYMPHOMA, INTRAPELVIC LYMPH NODES OTHER TYPES OF FOLLICULAR LYMPHOMA, SPLEEN OTHER TYPES OF FOLLICULAR LYMPHOMA, LYMPH NODES OF MULTIPLE SITES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 54

C8289 C8290 C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298 C8299 C8300 C8301 C8302 C8303 C8304 C8305 C8306 C8307 C8308 C8309 C8310 C8311 C8312 C8313 C8314 C8315 C8316 C8317 OTHER TYPES OF FOLLICULAR LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES FOLLICULAR LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE FOLLICULAR LYMPHOMA, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK FOLLICULAR LYMPHOMA, UNSPECIFIED, INTRATHORACIC LYMPH NODES FOLLICULAR LYMPHOMA, UNSPECIFIED, INTRA-ABDOMINAL LYMPH NODES FOLLICULAR LYMPHOMA, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB FOLLICULAR LYMPHOMA, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB FOLLICULAR LYMPHOMA, UNSPECIFIED, INTRAPELVIC LYMPH NODES FOLLICULAR LYMPHOMA, UNSPECIFIED, SPLEEN FOLLICULAR LYMPHOMA, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES FOLLICULAR LYMPHOMA, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES SMALL CELL B-CELL LYMPHOMA, UNSPECIFIED SITE SMALL CELL B-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK SMALL CELL B-CELL LYMPHOMA, INTRATHORACIC LYMPH NODES SMALL CELL B-CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES SMALL CELL B-CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB SMALL CELL B-CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB SMALL CELL B-CELL LYMPHOMA, INTRAPELVIC LYMPH NODES SMALL CELL B-CELL LYMPHOMA, SPLEEN SMALL CELL B-CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES SMALL CELL B-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES MANTLE CELL LYMPHOMA, UNSPECIFIED SITE MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES MANTLE CELL LYMPHOMA, SPLEEN May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 55

C8318 C8319 C8330 C8331 C8332 C8333 C8334 C8335 C8336 C8337 C8338 C8339 C8350 C8351 C8352 C8353 C8354 C8355 C8356 C8357 C8358 C8359 C8370 C8371 C8372 C8373 C8374 C8375 C8376 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MANTLE CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES DIFFUSE LARGE B-CELL LYMPHOMA, UNSPECIFIED SITE DIFFUSE LARGE B-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK DIFFUSE LARGE B-CELL LYMPHOMA, INTRATHORACIC LYMPH NODES DIFFUSE LARGE B-CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES DIFFUSE LARGE B-CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB DIFFUSE LARGE B-CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB DIFFUSE LARGE B-CELL LYMPHOMA, INTRAPELVIC LYMPH NODES DIFFUSE LARGE B-CELL LYMPHOMA, SPLEEN DIFFUSE LARGE B-CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES DIFFUSE LARGE B-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, UNSPECIFIED SITE LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, INTRATHORACIC LYMPH NODES LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, INTRAPELVIC LYMPH NODES LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, SPLEEN LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LYMPHOBLASTIC (DIFFUSE) LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES BURKITT LYMPHOMA, UNSPECIFIED SITE BURKITT LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK BURKITT LYMPHOMA, INTRATHORACIC LYMPH NODES BURKITT LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES BURKITT LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB BURKITT LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB BURKITT LYMPHOMA, INTRAPELVIC LYMPH NODES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 56

C8377 C8378 C8379 C8380 C8381 C8382 C8383 C8384 C8385 C8386 C8387 C8388 C8389 C8390 C8391 C8392 C8393 C8394 C8395 C8396 C8397 C8398 C8399 C8400 C8401 C8402 C8403 C8404 BURKITT LYMPHOMA, SPLEEN BURKITT LYMPHOMA, LYMPH NODES OF MULTIPLE SITES BURKITT LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES OTHER NON-FOLLICULAR LYMPHOMA, UNSPECIFIED SITE OTHER NON-FOLLICULAR LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK OTHER NON-FOLLICULAR LYMPHOMA, INTRATHORACIC LYMPH NODES OTHER NON-FOLLICULAR LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES OTHER NON-FOLLICULAR LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB OTHER NON-FOLLICULAR LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER NON-FOLLICULAR LYMPHOMA, INTRAPELVIC LYMPH NODES OTHER NON-FOLLICULAR LYMPHOMA, SPLEEN OTHER NON-FOLLICULAR LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER NON-FOLLICULAR LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, INTRATHORACIC LYMPH NODES NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, INTRA- ABDOMINAL LYMPH NODES NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, INTRAPELVIC LYMPH NODES NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, SPLEEN NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES NON-FOLLICULAR (DIFFUSE) LYMPHOMA, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES MYCOSIS FUNGOIDES, UNSPECIFIED SITE MYCOSIS FUNGOIDES, LYMPH NODES OF HEAD, FACE, AND NECK MYCOSIS FUNGOIDES, INTRATHORACIC LYMPH NODES MYCOSIS FUNGOIDES, INTRA-ABDOMINAL LYMPH NODES MYCOSIS FUNGOIDES, LYMPH NODES OF AXILLA AND UPPER LIMB May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 57

C8405 C8406 C8407 C8408 C8409 C8410 C8411 C8412 C8413 C8414 C8415 C8416 C8417 C8418 C8419 C8440 C8441 C8442 C8443 C8444 C8445 C8446 C8447 C8448 C8449 C8460 C8461 C8462 C8463 MYCOSIS FUNGOIDES, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MYCOSIS FUNGOIDES, INTRAPELVIC LYMPH NODES MYCOSIS FUNGOIDES, SPLEEN MYCOSIS FUNGOIDES, LYMPH NODES OF MULTIPLE SITES MYCOSIS FUNGOIDES, EXTRANODAL AND SOLID ORGAN SITES SEZARY DISEASE, UNSPECIFIED SITE SEZARY DISEASE, LYMPH NODES OF HEAD, FACE, AND NECK SEZARY DISEASE, INTRATHORACIC LYMPH NODES SEZARY DISEASE, INTRA-ABDOMINAL LYMPH NODES SEZARY DISEASE, LYMPH NODES OF AXILLA AND UPPER LIMB SEZARY DISEASE, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB SEZARY DISEASE, INTRAPELVIC LYMPH NODES SEZARY DISEASE, SPLEEN SEZARY DISEASE, LYMPH NODES OF MULTIPLE SITES SEZARY DISEASE, EXTRANODAL AND SOLID ORGAN SITES PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, UNSPECIFIED SITE PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, LYMPH NODES OF HEAD, FACE, AND NECK PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, INTRATHORACIC LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, INTRA- ABDOMINAL LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, INTRAPELVIC LYMPH NODES PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, SPLEEN PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, LYMPH NODES OF MULTIPLE SITES PERIPHERAL T-CELL LYMPHOMA, NOT CLASSIFIED, EXTRANODAL AND SOLID ORGAN SITES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, UNSPECIFIED SITE ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, LYMPH NODES OF HEAD, FACE, AND NECK ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, INTRATHORACIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, INTRA- ABDOMINAL LYMPH NODES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 58

C8464 C8465 C8466 C8467 C8468 C8469 C8470 C8471 C8472 C8473 C8474 C8475 C8476 C8477 C8478 C8479 C8490 C8491 C8492 C8493 C8494 C8495 C8496 C8497 ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, LYMPH NODES OF AXILLA AND UPPER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, INTRAPELVIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, SPLEEN ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, LYMPH NODES OF MULTIPLE SITES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-POSITIVE, EXTRANODAL AND SOLID ORGAN SITES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, UNSPECIFIED SITE ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, LYMPH NODES OF HEAD, FACE, AND NECK ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, INTRATHORACIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, INTRA- ABDOMINAL LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, LYMPH NODES OF AXILLA AND UPPER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, INTRAPELVIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, SPLEEN ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, LYMPH NODES OF MULTIPLE SITES ANAPLASTIC LARGE CELL LYMPHOMA, ALK-NEGATIVE, EXTRANODAL AND SOLID ORGAN SITES MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, UNSPECIFIED SITE MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, INTRATHORACIC LYMPH NODES MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, INTRA-ABDOMINAL LYMPH NODES MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, INTRAPELVIC LYMPH NODES MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, SPLEEN May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 59

C8498 C8499 C84A0 C84A1 C84A2 C84A3 C84A4 C84A5 C84A6 C84A7 C84A8 C84A9 C84Z0 C84Z1 C84Z2 C84Z3 C84Z4 C84Z5 C84Z6 C84Z7 C84Z8 C84Z9 C8510 C8511 C8512 MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED LYMPH NODES OF HEAD, FACE, AND NECK CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, INTRATHORACIC LYMPH NODES CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, INTRA-ABDOMINAL LYMPH NODES CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, INTRAPELVIC LYMPH NODES CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, SPLEEN CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES CUTANEOUS T-CELL LYMPHOMA, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES OTHER MATURE T/NK-CELL LYMPHOMAS, UNSPECIFIED SITE OTHER MATURE T/NK-CELL LYMPHOMAS, LYMPH NODES OF HEAD, FACE, AND NECK OTHER MATURE T/NK-CELL LYMPHOMAS, INTRATHORACIC LYMPH NODES OTHER MATURE T/NK-CELL LYMPHOMAS, INTRA-ABDOMINAL LYMPH NODES OTHER MATURE T/NK-CELL LYMPHOMAS, LYMPH NODES OF AXILLA AND UPPER LIMB OTHER MATURE T/NK-CELL LYMPHOMAS, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER MATURE T/NK-CELL LYMPHOMAS, INTRAPELVIC LYMPH NODES OTHER MATURE T/NK-CELL LYMPHOMAS, SPLEEN OTHER MATURE T/NK-CELL LYMPHOMAS, LYMPH NODES OF MULTIPLE SITES OTHER MATURE T/NK-CELL LYMPHOMAS, EXTRANODAL AND SOLID ORGAN SITES UNSPECIFIED B-CELL LYMPHOMA, UNSPECIFIED SITE UNSPECIFIED B-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK UNSPECIFIED B-CELL LYMPHOMA, INTRATHORACIC LYMPH NODES May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 60

C8513 C8514 C8515 C8516 C8517 C8518 C8519 C8520 C8521 C8522 C8523 C8524 C8525 C8526 C8527 C8528 C8529 C8580 C8581 C8582 C8583 C8584 C8585 C8586 C8587 UNSPECIFIED B-CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES UNSPECIFIED B-CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB UNSPECIFIED B-CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB UNSPECIFIED B-CELL LYMPHOMA, INTRAPELVIC LYMPH NODES UNSPECIFIED B-CELL LYMPHOMA, SPLEEN UNSPECIFIED B-CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES UNSPECIFIED B-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, UNSPECIFIED SITE MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, INTRATHORACIC LYMPH NODES MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, INTRAPELVIC LYMPH NODES MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, SPLEEN MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MEDIASTINAL (THYMIC) LARGE B-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, UNSPECIFIED SITE OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, INTRATHORACIC LYMPH NODES OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, INTRA- ABDOMINAL LYMPH NODES OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, INTRAPELVIC LYMPH NODES OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, SPLEEN May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 61

C8588 C8589 C8590 C8591 C8592 C8593 C8594 C8595 C8596 C8597 C8598 C8599 C860 C861 C862 C863 C864 C865 C866 C882 C883 C884 C888 C889 C9000 C9001 C9002 C9010 C9011 C9012 C9020 OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER SPECIFIED TYPES OF NON-HODGKIN LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES NON-HODGKIN LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE NON-HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF HEAD, FACE, AND NECK NON-HODGKIN LYMPHOMA, UNSPECIFIED, INTRATHORACIC LYMPH NODES NON-HODGKIN LYMPHOMA, UNSPECIFIED, INTRA-ABDOMINAL LYMPH NODES NON-HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF AXILLA AND UPPER LIMB NON-HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB NON-HODGKIN LYMPHOMA, UNSPECIFIED, INTRAPELVIC LYMPH NODES NON-HODGKIN LYMPHOMA, UNSPECIFIED, SPLEEN NON-HODGKIN LYMPHOMA, UNSPECIFIED, LYMPH NODES OF MULTIPLE SITES NON-HODGKIN LYMPHOMA, UNSPECIFIED, EXTRANODAL AND SOLID ORGAN SITES EXTRANODAL NK/T-CELL LYMPHOMA, NASAL TYPE HEPATOSPLENIC T-CELL LYMPHOMA ENTEROPATHY-TYPE (INTESTINAL) T-CELL LYMPHOMA SUBCUTANEOUS PANNICULITIS-LIKE T-CELL LYMPHOMA BLASTIC NK-CELL LYMPHOMA ANGIOIMMUNOBLASTIC T-CELL LYMPHOMA PRIMARY CUTANEOUS CD30-POSITIVE T-CELL PROLIFERATIONS HEAVY CHAIN DISEASE IMMUNOPROLIFERATIVE SMALL INTESTINAL DISEASE EXTRANODAL MARGINAL ZONE B-CELL LYMPHOMA OF MUCOSA- ASSOCIATED LYMPHOID TISSUE [MALT-LYMPHOMA] OTHER MALIGNANT IMMUNOPROLIFERATIVE DISEASES MALIGNANT IMMUNOPROLIFERATIVE DISEASE, UNSPECIFIED MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION MULTIPLE MYELOMA IN REMISSION MULTIPLE MYELOMA IN RELAPSE PLASMA CELL LEUKEMIA NOT HAVING ACHIEVED REMISSION PLASMA CELL LEUKEMIA IN REMISSION PLASMA CELL LEUKEMIA IN RELAPSE EXTRAMEDULLARY PLASMACYTOMA NOT HAVING ACHIEVED REMISSION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 62

C9021 C9022 C9030 C9031 C9032 C9100 C9101 C9102 C9110 C9111 C9112 C9130 C9131 C9132 C9140 C9141 C9142 C9150 C9151 C9152 C9160 C9161 C9162 C9190 C9191 C9192 C91A0 C91A1 C91A2 C91Z0 C91Z1 C91Z2 C9200 EXTRAMEDULLARY PLASMACYTOMA IN REMISSION EXTRAMEDULLARY PLASMACYTOMA IN RELAPSE SOLITARY PLASMACYTOMA NOT HAVING ACHIEVED REMISSION SOLITARY PLASMACYTOMA IN REMISSION SOLITARY PLASMACYTOMA IN RELAPSE ACUTE LYMPHOBLASTIC LEUKEMIA NOT HAVING ACHIEVED REMISSION ACUTE LYMPHOBLASTIC LEUKEMIA, IN REMISSION ACUTE LYMPHOBLASTIC LEUKEMIA, IN RELAPSE CHRONIC LYMPHOCYTIC LEUKEMIA OF B-CELL TYPE NOT HAVING ACHIEVED REMISSION CHRONIC LYMPHOCYTIC LEUKEMIA OF B-CELL TYPE IN REMISSION CHRONIC LYMPHOCYTIC LEUKEMIA OF B-CELL TYPE IN RELAPSE PROLYMPHOCYTIC LEUKEMIA OF B-CELL TYPE NOT HAVING ACHIEVED REMISSION PROLYMPHOCYTIC LEUKEMIA OF B-CELL TYPE, IN REMISSION PROLYMPHOCYTIC LEUKEMIA OF B-CELL TYPE, IN RELAPSE HAIRY CELL LEUKEMIA NOT HAVING ACHIEVED REMISSION HAIRY CELL LEUKEMIA, IN REMISSION HAIRY CELL LEUKEMIA, IN RELAPSE ADULT T-CELL LYMPHOMA/LEUKEMIA (HTLV-1-ASSOCIATED) NOT HAVING ACHIEVED REMISSION ADULT T-CELL LYMPHOMA/LEUKEMIA (HTLV-1-ASSOCIATED), IN REMISSION ADULT T-CELL LYMPHOMA/LEUKEMIA (HTLV-1-ASSOCIATED), IN RELAPSE PROLYMPHOCYTIC LEUKEMIA OF T-CELL TYPE NOT HAVING ACHIEVED REMISSION PROLYMPHOCYTIC LEUKEMIA OF T-CELL TYPE, IN REMISSION PROLYMPHOCYTIC LEUKEMIA OF T-CELL TYPE, IN RELAPSE LYMPHOID LEUKEMIA, UNSPECIFIED NOT HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA, UNSPECIFIED, IN REMISSION LYMPHOID LEUKEMIA, UNSPECIFIED, IN RELAPSE MATURE B-CELL LEUKEMIA BURKITT-TYPE NOT HAVING ACHIEVED REMISSION MATURE B-CELL LEUKEMIA BURKITT-TYPE, IN REMISSION MATURE B-CELL LEUKEMIA BURKITT-TYPE, IN RELAPSE OTHER LYMPHOID LEUKEMIA NOT HAVING ACHIEVED REMISSION OTHER LYMPHOID LEUKEMIA, IN REMISSION OTHER LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOBLASTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 63

C9201 C9202 C9210 C9211 C9212 C9220 C9221 C9222 C9230 C9231 C9232 C9240 C9241 C9242 C9250 C9251 C9252 C9260 C9261 C9262 C9290 C9291 C9292 C92A0 C92A1 C92A2 C92Z0 C92Z1 C92Z2 C9300 ACUTE MYELOBLASTIC LEUKEMIA, IN REMISSION ACUTE MYELOBLASTIC LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, BCR/ABL-POSITIVE, NOT HAVING ACHIEVED REMISSION CHRONIC MYELOID LEUKEMIA, BCR/ABL-POSITIVE, IN REMISSION CHRONIC MYELOID LEUKEMIA, BCR/ABL-POSITIVE, IN RELAPSE ATYPICAL CHRONIC MYELOID LEUKEMIA, BCR/ABL-NEGATIVE, NOT HAVING ACHIEVED REMISSION ATYPICAL CHRONIC MYELOID LEUKEMIA, BCR/ABL-NEGATIVE, IN REMISSION ATYPICAL CHRONIC MYELOID LEUKEMIA, BCR/ABL-NEGATIVE, IN RELAPSE MYELOID SARCOMA, NOT HAVING ACHIEVED REMISSION MYELOID SARCOMA, IN REMISSION MYELOID SARCOMA, IN RELAPSE ACUTE PROMYELOCYTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION ACUTE PROMYELOCYTIC LEUKEMIA, IN REMISSION ACUTE PROMYELOCYTIC LEUKEMIA, IN RELAPSE ACUTE MYELOMONOCYTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION ACUTE MYELOMONOCYTIC LEUKEMIA, IN REMISSION ACUTE MYELOMONOCYTIC LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA WITH 11Q23-ABNORMALITY NOT HAVING ACHIEVED REMISSION ACUTE MYELOID LEUKEMIA WITH 11Q23-ABNORMALITY IN REMISSION ACUTE MYELOID LEUKEMIA WITH 11Q23-ABNORMALITY IN RELAPSE MYELOID LEUKEMIA, UNSPECIFIED, NOT HAVING ACHIEVED REMISSION MYELOID LEUKEMIA, UNSPECIFIED IN REMISSION MYELOID LEUKEMIA, UNSPECIFIED IN RELAPSE ACUTE MYELOID LEUKEMIA WITH MULTILINEAGE DYSPLASIA, NOT HAVING ACHIEVED REMISSION ACUTE MYELOID LEUKEMIA WITH MULTILINEAGE DYSPLASIA, IN REMISSION ACUTE MYELOID LEUKEMIA WITH MULTILINEAGE DYSPLASIA, IN RELAPSE OTHER MYELOID LEUKEMIA NOT HAVING ACHIEVED REMISSION OTHER MYELOID LEUKEMIA, IN REMISSION OTHER MYELOID LEUKEMIA, IN RELAPSE ACUTE MONOBLASTIC/MONOCYTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 64

C9301 C9302 C9310 C9311 C9312 C9330 C9331 C9332 C9390 C9391 C9392 C93Z0 C93Z1 C93Z2 C9400 C9401 C9402 C9420 C9421 C9422 C9430 C9431 C9432 C9480 C9481 C9482 C9500 C9501 C9502 C9510 C9511 C9512 C9590 C9591 C9592 ACUTE MONOBLASTIC/MONOCYTIC LEUKEMIA, IN REMISSION ACUTE MONOBLASTIC/MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MYELOMONOCYTIC LEUKEMIA NOT HAVING ACHIEVED REMISSION CHRONIC MYELOMONOCYTIC LEUKEMIA, IN REMISSION CHRONIC MYELOMONOCYTIC LEUKEMIA, IN RELAPSE JUVENILE MYELOMONOCYTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION JUVENILE MYELOMONOCYTIC LEUKEMIA, IN REMISSION JUVENILE MYELOMONOCYTIC LEUKEMIA, IN RELAPSE MONOCYTIC LEUKEMIA, UNSPECIFIED, NOT HAVING ACHIEVED REMISSION MONOCYTIC LEUKEMIA, UNSPECIFIED IN REMISSION MONOCYTIC LEUKEMIA, UNSPECIFIED IN RELAPSE OTHER MONOCYTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION OTHER MONOCYTIC LEUKEMIA, IN REMISSION OTHER MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE ERYTHROID LEUKEMIA, NOT HAVING ACHIEVED REMISSION ACUTE ERYTHROID LEUKEMIA, IN REMISSION ACUTE ERYTHROID LEUKEMIA, IN RELAPSE ACUTE MEGAKARYOBLASTIC LEUKEMIA NOT HAVING ACHIEVED REMISSION ACUTE MEGAKARYOBLASTIC LEUKEMIA, IN REMISSION ACUTE MEGAKARYOBLASTIC LEUKEMIA, IN RELAPSE MAST CELL LEUKEMIA NOT HAVING ACHIEVED REMISSION MAST CELL LEUKEMIA, IN REMISSION MAST CELL LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIAS NOT HAVING ACHIEVED REMISSION OTHER SPECIFIED LEUKEMIAS, IN REMISSION OTHER SPECIFIED LEUKEMIAS, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE NOT HAVING ACHIEVED REMISSION ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN REMISSION ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE NOT HAVING ACHIEVED REMISSION CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN REMISSION CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE LEUKEMIA, UNSPECIFIED NOT HAVING ACHIEVED REMISSION LEUKEMIA, UNSPECIFIED, IN REMISSION LEUKEMIA, UNSPECIFIED, IN RELAPSE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 65

C960 C962 C964 C969 C96A C96Z D030 D0310 D0311 D0312 D0320 D0321 D0322 D0330 D0339 D034 D0351 D0352 D0359 D0360 D0361 D0362 D0370 D0371 D0372 D038 D039 D45 MULTIFOCAL AND MULTISYSTEMIC (DISSEMINATED) LANGERHANS- CELL HISTIOCYTOSIS MALIGNANT MAST CELL TUMOR SARCOMA OF DENDRITIC CELLS (ACCESSORY CELLS) MALIGNANT NEOPLASM OF LYMPHOID, HEMATOPOIETIC AND RELATED TISSUE, UNSPECIFIED HISTIOCYTIC SARCOMA OTHER SPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID, HEMATOPOIETIC AND RELATED TISSUE MELANOMA IN SITU OF LIP MELANOMA IN SITU OF UNSPECIFIED EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF RIGHT EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF LEFT EYELID, INCLUDING CANTHUS MELANOMA IN SITU OF UNSPECIFIED EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF RIGHT EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF LEFT EAR AND EXTERNAL AURICULAR CANAL MELANOMA IN SITU OF UNSPECIFIED PART OF FACE MELANOMA IN SITU OF OTHER PARTS OF FACE MELANOMA IN SITU OF SCALP AND NECK MELANOMA IN SITU OF ANAL SKIN MELANOMA IN SITU OF BREAST (SKIN) (SOFT TISSUE) MELANOMA IN SITU OF OTHER PART OF TRUNK MELANOMA IN SITU OF UNSPECIFIED UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF RIGHT UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF LEFT UPPER LIMB, INCLUDING SHOULDER MELANOMA IN SITU OF UNSPECIFIED LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF RIGHT LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF LEFT LOWER LIMB, INCLUDING HIP MELANOMA IN SITU OF OTHER SITES MELANOMA IN SITU, UNSPECIFIED POLYCYTHEMIA VERA May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 66

Step 12 (history of chemotherapy / radiation procedural code) Required procedure: 1 CPT Code Description 77261 RADIATION THERAPY PLANNING 77262 RADIATION THERAPY PLANNING 77263 RADIATION THERAPY PLANNING 77280 SET RADIATION THERAPY FIELD 77285 SET RADIATION THERAPY FIELD 77290 SET RADIATION THERAPY FIELD 77295 SET RADIATION THERAPY FIELD 77299 RADIATION THERAPY PLANNING 77300 RADIATION THERAPY DOSE PLAN 77301 RADIOLTHERAPY DOS PLAN, IMRT 77305 RADIATION THERAPY DOSE PLAN 77310 RADIATION THERAPY DOSE PLAN 77315 RADIATION THERAPY DOSE PLAN 77321 RADIATION THERAPY PORT PLAN 77326 RADIATION THERAPY DOSE PLAN 77327 RADIATION THERAPY DOSE PLAN 77328 RADIATION THERAPY DOSE PLAN 77331 SPECIAL RADIATION DOSIMETRY 77332 RADIATION TREATMENT AID(S) 77333 RADIATION TREATMENT AID(S) 77334 RADIATION TREATMENT AID(S) 77336 RADIATION PHYSICS CONSULT 77338 DESIGN MLC DEVICE FOR IMRT 77370 RADIATION PHYSICS CONSULT 77371 SRS, MULTISOURCE 77372 SRS, LINEAR BASED 77373 SBRT DELIVERY 77399 EXTERNAL RADIATION DOSIMETRY 77401 RADIATION TREATMENT DELIVERY 77402 RADIATION TREATMENT DELIVERY 77403 RADIATION TREATMENT DELIVERY 77404 RADIATION TREATMENT DELIVERY 77406 RADIATION TREATMENT DELIVERY 77407 RADIATION TREATMENT DELIVERY 77408 RADIATION TREATMENT DELIVERY May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 67

Step 12 (history of chemotherapy / radiation procedural code) Required procedure: 1 CPT Code Description 77409 RADIATION TREATMENT DELIVERY 77411 RADIATION TREATMENT DELIVERY 77412 RADIATION TREATMENT DELIVERY 77413 RADIATION TREATMENT DELIVERY 77414 RADIATION TREATMENT DELIVERY 77416 RADIATION TREATMENT DELIVERY 77417 RADIOLOGY PORT FILM(S) 77418 RADIATION TX DELIVERY, IMRT 77421 STEREOSCOPIC X-RAY GUIDANCE 77422 NEUTRON BEAM TX, SIMPLE 77423 NEUTRON BEAM TX, COMPLEX 77427 RADIATION TX MANAGEMENT, X5 77431 RADIATION THERAPY MANAGEMENT 77432 STEREOTACTIC RADIATION TRMT 77435 SBRT MANAGEMENT 77470 SPECIAL RADIATION TREATMENT 77499 RADIATION THERAPY MANAGEMENT 77520 PROTON TRMT, SIMPLE W/O COMP 77522 PROTON TRMT, SIMPLE W/COMP 77523 PROTON TRMT, INTERMEDIATE 77525 PROTON TREATMENT, COMPLEX 96401 CHEMO, ANTI-NEOPL, SQ/IM 96402 CHEMO HORMON ANTINEOPL SQ/IM 96405 CHEMO INTRALESIONAL, UP TO 7 96406 CHEMO INTRALESIONAL OVER 7 96409 CHEMO, IV PUSH, SNGL DRUG 96411 CHEMO, IV PUSH, ADDL DRUG 96413 CHEMO, IV INFUSION, 1 HR 96415 CHEMO, IV INFUSION, ADDL HR 96416 CHEMO PROLONG INFUSE W/PUMP 96417 CHEMO IV INFUS EACH ADDL SEQ 96420 CHEMO, IA, PUSH TECNIQUE 96422 CHEMO IA INFUSION UP TO 1 HR 96423 CHEMO IA INFUSE EACH ADDL HR 96425 CHEMOTHERAPY INFUSION METHOD May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 68

Step 12 (history of chemotherapy / radiation procedural code) Required procedure: 1 CPT Code Description 96440 CHEMOTHERAPY, INTRACAVITARY 96445 CHEMOTHERAPY, INTRACAVITARY 96450 CHEMOTHERAPY, INTO CNS 96521 REFILL/MAINT, PORTABLE PUMP 96542 CHEMOTHERAPY INJECTION 96549 CHEMOTHERAPY, UNSPECIFIED J9000 DOXORUBICIN HCL INJECTION J9001 DOXORUBICIN HCL LIPOSOME INJ J9010 ALEMTUZUMAB INJECTION J9015 ALDESLEUKIN INJECTION J9020 ASPARAGINASE INJECTION J9027 CLOFARABINE INJECTION J9033 BENDAMUSTINE INJECTION J9040 BLEOMYCIN SULFATE INJECTION J9041 BORTEZOMIB INJECTION J9045 CARBOPLATIN INJECTION J9050 CARMUSTINE INJECTION J9055 CETUXIMAB INJECTION J9060 CISPLATIN 10 MG INJECTION J9062 CISPLATIN 50 MG INJECTION J9065 INJ CLADRIBINE PER 1 MG J9070 CYCLOPHOSPHAMIDE 100 MG INJ J9080 CYCLOPHOSPHAMIDE 200 MG INJ J9090 CYCLOPHOSPHAMIDE 500 MG INJ J9091 CYCLOPHOSPHAMIDE 1.0 GRM INJ J9092 CYCLOPHOSPHAMIDE 2.0 GRM INJ J9093 CYCLOPHOSPHAMIDE LYOPHILIZED J9094 CYCLOPHOSPHAMIDE LYOPHILIZED J9095 CYCLOPHOSPHAMIDE LYOPHILIZED J9096 CYCLOPHOSPHAMIDE LYOPHILIZED J9097 CYCLOPHOSPHAMIDE LYOPHILIZED J9098 CYTARABINE LIPOSOME INJ J9100 CYTARABINE HCL 100 MG INJ J9110 CYTARABINE HCL 500 MG INJ J9120 DACTINOMYCIN INJECTION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 69

Step 12 (history of chemotherapy / radiation procedural code) Required procedure: 1 CPT Code J9130 J9140 J9150 J9151 J9155 J9160 J9170 J9171 J9178 J9181 J9182 J9185 J9190 J9200 J9201 J9206 J9207 J9208 J9211 J9261 J9263 J9264 J9265 J9266 J9268 J9280 J9290 J9291 J9303 J9305 J9320 J9328 J9330 J9340 J9350 Description DACARBAZINE 10 MG INJ DACARBAZINE 200 MG INJ DAUNORUBICIN INJECTION DAUNORUBICIN CITRATE INJ DEGARELIX INJECTION DENILEUKIN DIFTITOX INJ DOCETAXEL INJECTION DOCETAXEL INJECTION INJ, EPIRUBICIN HCL, 2 MG ETOPOSIDE INJECTION ETOPOSIDE 100 MG INJ FLUDARABINE PHOSPHATE INJ FLUOROURACIL INJECTION FLOXURIDINE INJECTION GEMCITABINE HCL INJECTION IRINOTECAN INJECTION IXABEPILONE INJECTION IFOSFOMIDE INJECTION IDARUBICIN HCL INJECTION NELARABINE INJECTION OXALIPLATIN PACLITAXEL PROTEIN BOUND PACLITAXEL INJECTION PEGASPARGASE INJECTION PENTOSTATIN INJECTION MITOMYCIN 5 MG INJ MITOMYCIN 20 MG INJ MITOMYCIN 40 MG INJ PANITUMUMAB INJECTION PEMETREXED INJECTION STREPTOZOCIN INJECTION TEMOZOLOMIDE INJECTION TEMSIROLIMUS INJECTION THIOTEPA INJECTION TOPOTECAN INJECTION May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 70

Step 12 (history of chemotherapy / radiation procedural code) Required procedure: 1 CPT Code Description J9355 TRASTUZUMAB INJECTION J9357 VALRUBICIN INJECTION J9360 VINBLASTINE SULFATE INJ J9370 VINCRISTINE SULFATE 1 MG INJ J9375 VINCRISTINE SULFATE 2 MG INJ J9380 VINCRISTINE SULFATE 5 MG INJ J9390 VINORELBINE TARTRATE INJ J9600 PORFIMER SODIUM INJECTION J9999 CHEMOTHERAPY DRUG ICD-9 Code Step 13 (diagnosis of active proliferative or severe Description non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days 36202 PROLIFERATIVE DIABETIC RETINOPATHY 36203 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS 36206 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY ICD-10 Code E103411 E103412 E103413 E103419 E103491 E103492 E103493 E103499 E103511 E103512 Description TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 71

E103513 E103519 E103521 E103522 E103523 E103529 E103531 E103532 E103533 E103539 E103541 E103542 E103543 E103549 E103551 E103552 E103553 E103559 Step 13 (diagnosis of active proliferative or severe non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, BILATERAL TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, BILATERAL TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, LEFT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, BILATERAL TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, UNSPECIFIED EYE TYPE 1 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, LEFT EYE TYPE 1 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, BILATERAL TYPE 1 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, UNSPECIFIED EYE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 72

E103591 E103592 E103593 E103599 E113411 E113412 E113413 E113419 E113491 E113492 E113493 E113499 E113511 E113512 E113513 E113519 E113521 E113522 E113523 E113529 E113531 E113532 Step 13 (diagnosis of active proliferative or severe non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 1 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, LEFT EYE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 73

E113533 E113539 E113541 E113542 E113543 E113549 E113551 E113552 E113553 E113559 E113591 E113592 E113593 E113599 E133411 E133412 E133413 E133419 Step 13 (diagnosis of active proliferative or severe non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, BILATERAL TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, LEFT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, BILATERAL TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, LEFT EYE TYPE 2 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, BILATERAL TYPE 2 DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, UNSPECIFIED EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 74

E133491 E133492 E133493 E133499 E133511 E133512 E133513 E133519 E133521 E133522 E133523 E133529 E133531 E133532 E133533 E133539 E133541 Step 13 (diagnosis of active proliferative or severe non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT INVOLVING THE MACULA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH TRACTION RETINAL DETACHMENT NOT INVOLVING THE MACULA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, RIGHT EYE May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 75

E133542 E133543 E133549 E133551 E133552 E133553 E133559 E133591 E133592 E133593 E133599 E13359 Step 13 (diagnosis of active proliferative or severe non-proliferative diabetic retinopathy) Required diagnosis: 1 Look back timeframe: 365 days OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH COMBINED TRACTION RETINAL DETACHMENT AND RHEGMATOGENOUS RETINAL DETACHMENT, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH STABLE PROLIFERATIVE DIABETIC RETINOPATHY, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, UNSPECIFIED EYE OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 76

Growth Hormone Serostim Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN SEROSTIM 4 MG VIAL 63405 SEROSTIM 5 MG VIAL 25955 SEROSTIM 6 MG VIAL 25960 May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 77

Growth Hormone Serostim Clinical PA Criteria Logic 1. Is the client greater than or equal to ( ) 17 years of age? [ ] Yes (Go to #2) [ ] No (Deny) 2. Does the client have a diagnosis of HIV in the last 3 years? [ ] Yes (Go to #3) [ ] No (Deny) 3. Does the client have a diagnosis of cachexia in the last 365 days? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have claims for greater than or equal to ( ) 2 single ingredient antiretroviral agents or a claim for a combination ingredient antiretroviral agent in the last 90 days? [ ] Yes (Go to #5) [ ] No (Deny) 5. Does the client have a diagnosis of active malignancy in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #6) 6. Does the client have a history of chemotherapy/radiation (CPTs) in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #7) 7. Does the client have a diagnosis of active proliferative or severe nonproliferative diabetic retinopathy in the last 365 days? [ ] Yes (Deny) [ ] No (Approve 48 weeks) May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 78

Growth Hormone Serostim Clinical PA Criteria Logic Diagram Step 1 Is the client 17 years of age? Yes Step 2 Does the client have a diagnosis of HIV in the last 3 years? Yes Step 3 Does the client have a diagnosis of cachexia in the last 365 days? Yes Step 4 Does the client have claims for 2 single ingredient antiretroviral agents or a claim for a combination ingredient antiretroviral agent in the last 90 days? No Deny Request No No No Yes Deny Request Deny Request Deny Request Step 5 Does the client have a diagnosis of active malignancy in the last 180 days? Yes Deny Request No Step 6 Does the client have a history of chemotherapy/ radiation the last 180 days? Yes Deny Request No Step 7 Does the client have a history of active proliferative or severe nonproliferative diabetic retinopathy in the last 365 days? Yes Deny Request No Approve Request (48 weeks) May 11, 2017 Copyright 2011-2017 Health Information Designs, LLC 79