CUSTOMIZATIONS TO MILLIMAN CARE GUIDELINES 15 th EDITION Original Date: March 3, 2011

Issue Date: July 19, 2011 CUSTOMIZATIONS TO MILLIMAN CARE GUIDELINES 15 th EDITION Original Date: March 3, 2011 NOTE: This document provides a high level summary of customizations and modifications made to Milliman Care Guidelines (hereinafter referred to as Customized Guidelines ). Customized Guidelines are available on request. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the Customized Guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, as well as applicable state and/or federal law. The Customized Guidelines do not constitute plan authorization or a guarantee of payment, nor are they an explanation of benefits. We reserve the right to review and modify the Milliman Care Guidelines or Customized Guidelines at any time. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. The 15 th Edition of the Milliman Care Guidelines and corresponding Customized Guidelines will take effect June 6, 2011. The February 17, 2011, MPTAC review date reflects review and approval of (a) the licensed Milliman Care Guidelines 15 th Edition, (b) customizations from the 14th Edition carried over to the 15th Edition and (c) new customizations to the 15th Edition. New customizations include the following: o ISC Cardiac Septal Defect: Ventricular, Repair o ISC Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy or Sleeve Gastrectomy by Laparoscopy o ISC Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy The May 19, 2011, MPTAC review date reflects review and approval of new customizations to the 15th Edition. New customizations include the following: o ISC Laparoscopic Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy o ISC Laparotomy for Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy INDEX (CTRL + Click to follow link) CUSTOMIZATIONS - BACKGROUND INFORMATION CUSTOMIZATIONS - INPATIENT AND SURGICAL CARE GUIDELINES BEHAVIORAL HEALTH Issue Date: July 19, 2011 R2 Page 1 of 13

o Behavioral Health Guidelines o Delirium o Substance Abuse, Dependence, or Withdrawal CARDIOLOGY o Angioplasty, Percutaneous Coronary Intervention o Atrial Fibrillation o Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion, Transvenous o Electrophysiologic Study and Intracardiac Catheter Ablation CARDIOVASCULAR (CV) SURGERY o Aortic Aneurysm, Abdominal, Endovascular Repair o Cardiac Septal Defect: Atrial, Transcatheter Closure o Cardiac Septal Defect: Ventricular, Repair o Cardiac Valve Replacement or Repair o Carotid Endarterectomy o Coronary Artery Bypass Graft (CABG) o Coronary Artery Bypass Graft, Minimally Invasive Direct (MIDCAB) o Heart Transplant o Sympathectomy by Thoracoscopy or Laparoscopy COMMON COMPLICATIONS AND CONDITIONS o Preoperative Days GASTROENTEROLOGY o Liver Disease Complications GENERAL SURGERY o Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy or Sleeve Gastrectomy by Laparoscopy o Gastric Restrictive Procedure with or without Gastric Bypass o Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy o Liver Transplant o Mastectomy, Complete o Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander o Mastectomy, Complete, with Tissue Flap Reconstruction o Mastectomy, Partial (Lumpectomy) NEONATAL LEVEL OF CARE GUIDELINES o Neonatal Care Guidelines NEUROLOGY o Headaches OBSTETRICS AND GYNECOLOGY o Cesarean Delivery o Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted o Laparoscopic Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy o Laparotomy for Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy o Preterm Labor, Threatened o Vaginal Delivery o Vaginal Delivery, Operative ORTHOPEDICS o Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy o Knee Arthroplasty o Knee Arthroscopy Issue Date: July 19, 2011 R2 Page 2 of 13

o Knee: Patella Reconstruction or Realignment o Lumbar Diskectomy, Foraminotomy, or Laminotomy o Lumbar Fusion PEDIATRICS o Newborn Care THORACIC SURGERY AND PULMONARY DISEASE o Lung Transplant UROLOGY o Prostatectomy, Transurethral, Alternatives to Standard Resection o Renal Transplant CUSTOMIZATIONS - GENERAL RECOVERY GUIDELINES (GRG) BEHAVIORAL HEALTH o Behavioral Health Guidelines GENERAL RECOVERY GUIDELINES TOOLS SECTION o Inpatient Palliative Care Criteria PROBLEM ORIENTED GRG o Medical Oncology CUSTOMIZATIONS RECENT UPDATES (May 19, 2011 MPTAC) Guidelines o Laparoscopic Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy o Laparotomy for Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy CUSTOMIZATION HISTORY CUSTOMIZATIONS BACKGROUND INFORMATION Types of : 1. to Milliman Care Guidelines clinical indications based on integration with our medical policy and clinical UM guidelines. 2. to Milliman Care Guidelines clinical indications with changes to the original Milliman criteria which includes adding or revising appropriateness criteria. 3. to Milliman Care Guidelines goal length of stay with changes to the original Milliman criteria. 4. Other customizations to Milliman Care Guidelines may include adding reference(s), adding a Related Guidelines section with our related medical policy or clinical UM guidelines or other changes to Milliman Care Guidelines, e.g., revision to Alternatives for Procedure. Review and Approval of : Issue Date: July 19, 2011 R2 Page 3 of 13

The Medical Policy & Technology Assessment Committee (MPTAC) reviews and approves all customizations to Milliman Care Guidelines. In addition, when a new edition of Milliman Care Guidelines is released, the new edition is approved by the MPTAC. Disclaimer: Customized Guidelines include a disclaimer at the top of the guideline after the guideline title indicating: This guideline has been modified from the content of the Milliman Care Guidelines. Milliman has not approved and accepts no responsibility for the modified material. Any statement to the contrary or association of the modified material with Milliman is strictly prohibited. Guideline History: All Customized Guidelines include a Guideline History section that provides (1) the date of the Medical Policy & Technology Assessment Committee (MPTAC) meeting review and approval of the customization, and (2) a summary of the customization to the Milliman Care Guideline. CUSTOMIZATIONS INPATIENT AND SURGICAL CARE GUIDELINES Behavioral Health Behavioral Health (BH) All BH guidelines Behavioral Health (BH) Delirium Behavioral Health (BH) Substance Abuse, Dependence, or Withdrawal Approval of February 11, 2011 Behavioral Health Subcommittee review February 11, 2011 Behavioral Health Subcommittee review: NOTE: The Behavioral Health Guidelines (ISC and GRG) were removed (with the exception of those ISC guidelines noted as reinstated) Approval of February 11, 2011 Behavioral Health Subcommittee review February 11, 2011 Behavioral Health Subcommittee review: Continue to reinstate guideline for Delirium Approval of February 11, 2011 Behavioral Health Subcommittee review February 11, 2011 Behavioral Health Subcommittee review: Continue to reinstate guideline for Substance Abuse, Dependence, or Withdrawal Revised: Alternatives to Admission. Refer to Behavioral Health Medical Necessity Criteria for Alternatives to Admission: o Acute outpatient care: see Behavioral Health Medical Necessity Criteria: Substance Abuse, Outpatient Treatment o Intensive outpatient program (IOP) see Behavioral Health Medical Necessity Criteria: Substance Abuse, Intensive Structured Outpatient Rehabilitation Program (IOP) o Partial hospital program (PHP) see Behavioral Health Medical Necessity Criteria: Substance Abuse, Partial Hospitalization Rehabilitation Program (PHP) o Residential care see Behavioral Health Medical Necessity Criteria: Substance Abuse, Subacute/Residential Treatment Center (RTC) Detoxification; Substance Abuse, Subacute/RTC Rehabilitation Issue Date: July 19, 2011 R2 Page 4 of 13

Cardiology Cardiology - Angioplasty, Percutaneous Coronary Intervention Cardiology - Atrial Fibrillation Cardiology - Electrophysiologic Study and Implantable Cardioverter- Defibrillator (ICD) Insertion, Transvenous Cardiology - Electrophysiologic Study and Intracardiac Catheter Ablation Revised Alternatives to Procedure: o For transmyocardial laser revascularization, footnote D, revised to indicate: For information on transmyocardial laser revascularization, see SURG.00019 Transmyocardial Revascularization Added Related Guidelines section with related medical policy o MED.00098 Hyperoxemic Reperfusion Therapy o RAD.00016 Intravascular Brachytherapy (Coronary and Non-Coronary) o SURG.00019 Transmyocardial Revascularization o TRANS.00022 Autologous Cell Therapy for the Treatment of Damaged Myocardium Added Related Guidelines section with related medical policy and clinical UM guidelines o MED.00041 Microvolt T-Wave Alternans o MED.00051 Real-Time Remote Heart Monitors o MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation) o MED.00074 Computer Analysis of Electrocardiography (ECG) o CG-DME-29 Ambulatory Event Monitors to Detect Cardiac Arrhythmias o CG-DME-30 Prothrombin Time Self-Monitoring Devices o CG-SURG-05 Maze Procedure Revised Clinical Indications for Procedure: For electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) see the following: o SURG.00033 Implantable Cardioverter-Defibrillator (ICD) o SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Added Related Guidelines section with related medical policy o DME.00032 Automated External Defibrillators for Home Use o MED.00055 Wearable Cardioverter Defibrillators o SURG.00033 Implantable Cardioverter-Defibrillator (ICD) o SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Included note under Clinical Indications for Procedure: For transcatheter ablation of arrhythmogenic foci in the pulmonary veins as a treatment of atrial fibrillation (radiofrequency and cryoablation), see MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation) Added Related Guidelines section with related medical policy and clinical UM guidelines o MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation) o SURG.00033 Implantable Cardioverter-Defibrillator (ICD) o SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure o CG-SURG-05 Maze Procedure Cardiovascular (CV) Surgery Aortic Aneurysm, Abdominal, Endovascular Repair Revised Clinical Indications for Procedure: For abdominal aortic aneurysm, endovascular repair, see SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms Cardiac Included note under Clinical Indications for Procedure: For transcatheter closure of patent foramen Issue Date: July 19, 2011 R2 Page 5 of 13

Septal Defect: Atrial, Transcatheter Closure Cardiac Septal Defect: Ventricular, Repair Cardiac Valve Replacement or Repair Carotid Endarterectomy Coronary Artery Bypass Graft (CABG) Coronary Artery Bypass Graft, Minimally Invasive Direct (MIDCAB) Heart Transplant Sympathectomy by Thoracoscopy or Laparoscopy ovale (PFO) and left atrial appendage closure for stroke prevention, see SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention Included note under Clinical Indications for Procedure: For transmyocardial/perventricular device closure of ventricular septal defects, see SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects Included note under Clinical Indications for Procedure: When the procedure uses the transcatheter approach (as opposed to open), see SURG.00121 Transcatheter Heart Valves Revised Alternatives to Procedure: o For information on carotid, vertebral and intracranial artery angioplasty with or without stent placement, see SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement Revised Alternatives to Procedure: o For transmyocardial laser revascularization, footnote B, revised to indicate: For information on transmyocardial laser revascularization, see SURG.00019 Transmyocardial Revascularization o For enhanced external counterpulsation, footnote C, revised to indicate: For information on enhanced external counterpulsation in the outpatient setting, see MED.00010 Enhanced External Counterpulsation (EECP) in the Outpatient Setting Revised Alternatives to Procedure: o For transmyocardial laser revascularization, footnote B, revised to indicate: For information on transmyocardial laser revascularization, see SURG.00019 Transmyocardial Revascularization o For enhanced external counterpulsation, footnote C, revised to indicate: For information on enhanced external counterpulsation in the outpatient setting, see MED.00010 Enhanced External Counterpulsation (EECP) in the Outpatient Setting Revised Clinical Indications for Procedure: For heart transplant, see the following: o TRANS.00026 Heart/Lung Transplantation o TRANS.00033 Heart Transplantation Revised Clinical Indications for Procedure: For treatment of hyperhidrosis, see the following: MED.00032 Treatment of Hyperhidrosis Common Complications and Conditions Preoperative Days Preoperative Days Included an additional indication for inpatient preoperative days: Conversion from warfarin (Coumadin ) to IV heparin for patients with mechanical heart valves or other high risk patients with contraindications to low-molecular-weight heparin (LMWH) or fractionated heparin (one to two days inpatient stay before elective surgery) Added reference, ACC/AHA guidelines for the management of patients with valvular heart disease Gastroenterology Issue Date: July 19, 2011 R2 Page 6 of 13

Gastroenterology - Liver Disease Complications General Surgery Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy Title change to: Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy or Sleeve Gastrectomy by Laparoscopy Gastric Restrictive Procedure with Gastric Bypass Title change to: Gastric Restrictive Procedure with or without Gastric Bypass Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy Liver Transplant Mastectomy, Complete Revised Clinical Indications for Admission to Inpatient Care: For acute hepatitis, revised bilirubin greater than 20 mg/dl (342 micromoles/l) to indicate bilirubin greater than 10 mg/dl (171 micromoles/l) Title changed from Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy to indicate Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy or Sleeve Gastrectomy by Laparoscopy Revised Clinical Indications for Procedure: For gastric restrictive procedure with gastric bypass by laparoscopy or sleeve gastrectomy by laparoscopy, see the following: o SURG.00024 Surgery for Clinically Severe Obesity Revised Alternatives to Procedure: Removed: o Sleeve gastrectomy Added Code: CPT 43775 Revised Clinical Indications for Procedure: For gastric restrictive procedure with or without gastric bypass, see the following: SURG.00024 Surgery for Clinically Severe Obesity Title changed from Gastric Restrictive Procedure with Gastric Bypass to indicate Gastric Restrictive Procedure with or without Gastric Bypass Added Codes: CPT 43842, 43843 Revised Clinical Indications for Procedure: For gastric restrictive procedure without gastric bypass by laparoscopy, see SURG.00024 Surgery for Clinically Severe Obesity Revised Clinical Indications for Procedure: For liver transplant, see TRANS.00008 Liver Transplantation Revised Clinical Indications for Procedure: o For risk-reduction mastectomy, added atypical hyperplasia as an example of noninvasive histology o For risk-reduction mastectomy, added indication, extensive mammographic abnormalities (e.g., calcifications) exist such that adequate biopsy is impossible Information regarding Federal or State mandates will supersede the guideline Length of Stay when Revised Goal Length of Stay (GLOS) to indicate 2 days postoperative rather than Ambulatory Added the following: o Reason: Organization approved 2 day stay o Context: Organization accepted variance of 2 days Revised Operative Status Criteria to indicate Inpatient rather than Ambulatory Issue Date: July 19, 2011 R2 Page 7 of 13

Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander Mastectomy, Complete, with Tissue Flap Reconstruction Mastectomy, Partial (Lumpectomy) Revised Clinical Indications for Procedure: o For risk-reduction mastectomy, added atypical hyperplasia as an example of noninvasive histology o For risk-reduction mastectomy, added indication, extensive mammographic abnormalities (e.g., calcifications) exist such that adequate biopsy is impossible Information regarding Federal or State mandates will supersede the guideline Length of Stay when Revised Goal Length of Stay (GLOS) to indicate 2 days postoperative rather than Ambulatory or 1 day postoperative Added the following: o Reason: Organization approved 2 day stay o Context: Organization accepted variance of 2 days Revised Operative Status Criteria to indicate Inpatient rather than Ambulatory or Inpatient Revised Clinical Indications for Procedure: o For risk reduction mastectomy, added atypical hyperplasia as an example of noninvasive histology o For risk reduction mastectomy, added indication, extensive mammographic abnormalities (e.g., calcifications) exist such that adequate biopsy is impossible Information regarding Federal or State mandates will supersede the guideline Length of Stay when Information regarding Federal or State mandates will supersede the guideline Length of Stay when Revised Goal Length of Stay (GLOS) to indicate 2 days postoperative rather than Ambulatory Added the following: o Reason: Organization approved 2 day stay o Context: Organization accepted variance of 2 days Revised Operative Status Criteria to indicate Inpatient rather than Ambulatory Neonatal Level of Care Guidelines Neonatal Level of Care Guidelines Level I Neonatal Care Guidelines NOTE: The guidelines for Neonatal Level of Care were removed. For Neonatal Levels of Care, see CG-MED-26 Neonatal Levels of Care. Level II Neonatal Care Guidelines Level III Neonatal Care Guidelines Neurology Neurology - Headaches Revised Clinical Indications for Admission to Inpatient Care: Added "or severe migraine unresponsive to outpatient interventions" to: Severe headache with intractable vomiting and dehydration unresponsive to outpatient interventions, or severe migraine unresponsive to outpatient interventions Added Related Guidelines section with related medical policy and clinical UM guidelines o DRUG.00006 Botulinum Toxin o DRUG.00030 Histamine Desensitization Therapy o MED.00023 Biofeedback Therapy and Neurofeedback o MED.00108 Transcranial Magnetic Stimulation for Non-Behavioral Health Indications o SURG.00026 Deep Brain Stimulation o SURG.00096 Surgical Treatment of Migraine Headaches o SURG.00112 Occipital Nerve Stimulation o CG-ANC-03 Acupuncture Issue Date: July 19, 2011 R2 Page 8 of 13

o o o CG-DME-18 Home Oxygen Therapy CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults CG-SURG-17 Trigger Point Injections Obstetrics and Gynecology OB / GYN - Cesarean Delivery Information regarding Federal or State mandates will supersede the guideline Length of Stay when OB / GYN - Hysterectomy, Laparoscopic Title changed from Hysterectomy, Laparoscopic to indicate: Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted Title change to: Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopicallyassisted OB / GYN - Laparoscopic Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy OB / GYN - Laparotomy for Gynecologic Surgery Including Myomectomy, Oophorectomy, and Salpingectomy May 19, 2011 MPTAC review: Revised Clinical Indications for Procedure: o Bilateral prophylactic oophorectomy changed to risk reducing salpingo-oophorectomy o Additional indication listed for risk reducing salpingo-oophorectomy: The presence of two or more first degree relatives (e.g., mother, sister, daughter) or one first degree relative and one or more second degree relatives (maternal or paternal grandmother, aunt or niece) with a history of ovarian cancer Revised Clinical Indications for Procedure: o For bilateral prophylactic oophorectomy, added indications Lynch syndrome II mutation A personal history of breast cancer, which is estrogen receptor positive and/or progesterone receptor positive, and premenopausal Revised Alternatives to Procedure: For uterine artery embolization for leiomyomas, see CG-SURG-28 Transcatheter Uterine Artery Embolization Added Related Guidelines section with related medical policy and clinical UM guidelines o MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids o SURG.00062 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome o SURG.00077 Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids o CG-SURG-28 Transcatheter Uterine Artery Embolization May 19, 2011 MPTAC review: Revised Clinical Indications for Procedure: o Bilateral prophylactic oophorectomy changed to risk reducing salpingo-oophorectomy o Additional indication listed for risk reducing salpingo-oophorectomy: The presence of two or more first degree relatives (e.g., mother, sister, daughter) or one first degree relative and one or more second degree relatives (maternal or paternal grandmother, aunt or niece) with a history of ovarian cancer Revised Clinical Indications for Procedure: o For bilateral prophylactic oophorectomy, added indications Lynch syndrome II mutation A personal history of breast cancer, which is estrogen receptor positive and/or Issue Date: July 19, 2011 R2 Page 9 of 13

progesterone receptor positive, and premenopausal Revised Alternatives to Procedure: For uterine artery embolization for leiomyomas, see CG-SURG-28 Transcatheter Uterine Artery Embolization Added Related Guidelines section with related medical policy and clinical UM guidelines o MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids o SURG.00062 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome o SURG.00077 Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids o CG-SURG-28 Transcatheter Uterine Artery Embolization OB / GYN - 14h Ed: Preterm Labor, Threatened Revised Clinical Indications for Admission to Inpatient Care: Included placenta previa with vaginal bleeding under clinical indications for admission to inpatient care. Added reference Wing DA, Paul RH, Millar LK (1996) OB / GYN - Vaginal Delivery OB/GYN - Vaginal Delivery, Operative Orthopedics Orthopedics - Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy Orthopedics - Knee Arthroplasty Information regarding Federal or State mandates will supersede the guideline Length of Stay when Information regarding Federal or State mandates will supersede the guideline Length of Stay when Included note under Clinical Indications for Procedure: When the procedure uses the percutaneous or endoscopic approach (as opposed to open with direct visualization), see SURG.00071 Percutaneous and Endoscopic Spinal Surgery. Included note under Clinical Indications for Procedure: When the procedure uses recombinant human bone morphogenetic protein, see SURG.00059 Recombinant Human Bone Morphogenetic Protein. Revised Goal Length of Stay to indicate Ambulatory or 1 day postoperative rather than Ambulatory Revised Operative Status Criteria to indicate o Ambulatory: Procedure without postoperative drain in place o Inpatient: Drain management may require an overnight stay Revised Extended Stay to include: o Drain management may require minimal stay extension Added Related Guidelines section with related medical policy o RAD.00053 Cervical and Thoracic Discography o SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty) o SURG.00055 Artificial Intervertebral Discs o SURG.00059 Recombinant Human Bone Morphogenetic Protein o SURG.00071 Percutaneous and Endoscopic Spinal Surgery o SURG.00092 Implanted Devices for Spinal Stenosis May 19, 2011 review: Title change for SURG.00082: o New title: Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System o Formerly titled: Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures Included note under Clinical Indications for Procedure: When the procedure uses computer-assisted musculoskeletal surgical navigation, see SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures Included note under Clinical Indications for Procedure: For bicompartmental knee arthroplasty, see Issue Date: July 19, 2011 R2 Page 10 of 13

Orthopedics - Knee Arthroscopy Orthopedics - Knee: Patella Reconstruction or Realignment Orthopedics - Lumbar Diskectomy, Foraminotomy, Laminotomy Orthopedics - Lumbar Fusion SURG.00105 Bicompartmental Knee Arthroplasty Revised Clinical Indications for Procedure: o For debridement, drainage or lavage, added the following note: o NOTE: For osteoarthritis of the knee, see medically necessary and not medically necessary indications listed in CG-SURG-23 Arthroscopic Lavage and Arthroscopic Debridement as a Treatment for Osteoarthritis of the Knee Revised Alternatives to Procedure: o For information on knee immobilizers and braces, indicated to see CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces or CG-OR-PR-03 Custom-made Knee Braces Included note under Clinical Indications for Procedure: When the procedure uses the percutaneous or endoscopic approach (as opposed to open with direct visualization), see SURG.00071 Percutaneous and Endoscopic Spinal Surgery. Added Related Guidelines section with related medical policy and clinical UM guidelines o SURG.00052 Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty) o SURG.00055 Artificial Intervertebral Discs o SURG.00059 Recombinant Human Bone Morphogenetic Protein o SURG.00071 Percutaneous and Endoscopic Spinal Surgery o SURG.00092 Implanted Devices for Spinal Stenosis o CG-SURG-29 Lumbar Discography Included note under Clinical Indications for Procedure: When the procedure uses the percutaneous or endoscopic approach (as opposed to open with direct visualization), see SURG.00071 Percutaneous and Endoscopic Spinal Surgery. Revised Clinical Indications for Procedure: Removed: o Lumbar spinal stenosis treatment indicated by ALL of the following: Imaging findings of lumbar spondylolisthesis Clinically important findings of spinal stenosis indicated by 1 or more of the following: Progressive or severe symptoms of neurogenic claudication Back pain or radicular pain requiring treatment as indicated by ALL of the following: Significant functional impairment Central, lateral recess or foraminal stenosis demonstrated on imaging (eg, MRI, CT, myelography) Failure of at least 3 months of nonoperative therapy o Spondylolysis treatment indicated by 1 or more of the following: Rapidly progressive spondylolisthesis with severe neurologic compromise (eg, urinary incontinence) Spondylolisthesis with significant associated findings, including ALL of the following: High-grade (ie, 50% or more anterior slippage) spondylolisthesis demonstrated on plain x-rays Back pain, neurogenic claudication symptoms, or radicular pain from lateral recess or foraminal stenosis Significant functional impairment Failure of at least 3 months of nonoperative therapy Added: o Moderate to severe lumbar spinal stenosis associated with lumbar spondylolisthesis or with evidence of spinal instability, either pre-existing or anticipated due to the need for bilateral decompression or wide decompression involving facetectomy or resection of pars interarticularis o Spondylolisthesis with 1 or more of the following: Progressive deformity or neurologic compromise Issue Date: July 19, 2011 R2 Page 11 of 13

Pediatric (age <=18) patients with high-grade (ie, 50% or more anterior slippage) spondylolisthesis demonstrated on x-ray Adult patients (age >18) with persistent and significantly symptomatic, despite an adequate trial of at least 6 months of conservative care, low- or high-grade spondylolisthesis demonstrated on x-ray o As a surgical adjunct to disc excision or re-operative discectomy in patients with radiculopathy secondary to a herniated disc in whom there is documented radiographic evidence of preoperative lumbar spinal instability (e.g., anterolisthesis, retrolisthesis, spondylolisthesis) o Added indications for when a lumbar fusion is considered not medically necessary Lumbar fusion is considered not medically necessary when one of the indications listed is not present, including but not limited to: As a procedure following primary disc excision, including patients with a herniated lumbar disc causing radiculopathy As a treatment of low back pain due to degenerative disc disease or degenerative lumbar spondylosis without stenosis or spondylolisthesis Added references Added Related Guidelines section with related medical policy o SURG.00059 Recombinant Human Bone Morphogenetic Protein o SURG.00071 Percutaneous and Endoscopic Spinal Surgery o SURG.00075 Intervertebral Stabilization Devices Pediatrics Pediatrics 15 th Ed: Newborn Care Information regarding Federal or State mandates will supersede the guideline Length of Stay when Thoracic Surgery and Pulmonary Disease Thoracic Surgery and Pulmonary Revised Clinical Indications for Procedure: For lung transplant see the following: Disease - o TRANS.00009 Lung and Lobar Transplantation Lung Transplant o TRANS.00026 Heart/Lung Transplantation Urology Urology - Prostatectomy, Transurethral, Alternatives to Standard Resection Urology - Renal Transplant Included note under Clinical Indications for Procedure: For additional information on surgical and minimally invasive procedures for benign prostatic hyperplasia (BPH) considered medically necessary, not medically necessary, or investigational and not medically necessary, including water-induced thermotherapy (WIT), also known as thermourethral hot-water therapy, when used as an alternative to open prostatectomy or transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia see the following: SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions Revised Clinical Indications for Procedure: For renal transplant, see CG-TRANS-02 Kidney Transplantation CUSTOMIZATIONS - GENERAL RECOVERY GUIDELINES (GRG) General Recovery Guideline (GRG) Issue Date: July 19, 2011 R2 Page 12 of 13

General Recovery Guideline (GRG) Behavioral Health Behavioral Health (BH) Body System GRG Case Management GRG Care Management Tools Behavioral Health Levels of Care NOTE: The Behavioral Health Guidelines (ISC and GRG) were removed (with the exception of those ISC guidelines noted as reinstated). The Milliman Behavioral Health Guidelines in the General Recovery Guideline module are not used by this health plan. General Recovery Guidelines Tools Section General Recovery Guidelines Tools Added section on Alternatives to Admission Section Inpatient Palliative Care Criteria Added reference for Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch 9 Coverage of hospice services under hospital insurance Problem Oriented GRG Problem Oriented Medical Oncology GRG Included note under Clinical Indications for Admission to Inpatient Care: o For radioactive implant treatments needing inpatient environment, added note for inpatient admission for radiation therapy for cervical or thyroid cancer, see CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer CUSTOMIZATION HISTORY Date Action Reason 07/19/2011 Release updated document for to Milliman Care Guidelines 15th Edition Updated document for to Milliman Care Guidelines 15th Edition. See Index for customizations recent updates (May 19, 2011 MPTAC). 03/03/2011 Release document for to Milliman Care Guidelines 15th Edition New document for to Milliman Care Guidelines 15th Edition. The 15th Edition of the Milliman Care Guidelines and corresponding Customized Guidelines will take effect June 6, 2011. Issue Date: July 19, 2011 R2 Page 13 of 13