CUSTOMIZATIONS TO MILLIMAN CARE GUIDELINES 13 th EDITION Issue Date: December 10, 2009

CUSTOMIZATIONS TO MILLIMAN CARE GUIDELINES 13 th EDITION Issue Date: December 10, 2009 Original Date: March 9, 2009 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. INDEX CUSTOMIZATIONS - BACKGROUND INFORMATION CUSTOMIZATIONS - INPATIENT AND SURGICAL CARE GUIDELINES BEHAVIORAL HEALTH 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 o Supraventricular Arrhythmias CARDIOVASCULAR (CV) SURGERY o Aortic Aneurysm, Abdominal, Endovascular Repair o Aortic Aneurysm, Abdominal, Repair or Excision with Graft Replacement o Cardiac Septal Defect: Atrial, Transcatheter Closure o Carotid Endarterectomy o Coronary Artery Bypass Graft (CABG) o Coronary Artery Bypass Graft, Minimally Invasive Direct (MIDCAB) o Heart Transplant o Patent Ductus Arteriosus, Transcatheter Coil Occlusion o Sympathectomy by Thoracoscopy or Laparoscopy Issue Date: December 10, 2009 R3 Page 1 of 13

COMMON COMPLICATIONS AND CONDITIONS o Preoperative Days ENDOCRINOLOGY o Parathyroidectomy o Thyroidectomy GASTROENTEROLOGY o Liver Disease Complications GENERAL SURGERY o Cholecystectomy by Laparoscopy o Gastric Restrictive Procedure with Gastric Bypass o Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy o Gastric Restrictive Procedure without Gastric Bypass o Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy o Liver Transplant o Mastectomy, Modified Radical o Mastectomy, Partial (Lumpectomy) with Axillary Lymphadenectomy o Mastectomy, Modified Radical, with Insertion of Breast Prosthesis or Tissue Expander o Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap o Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap and Microvascular Anastomosis NEONATAL LEVEL OF CARE GUIDELINES o Neonatal Care Guidelines NEUROLOGY o Headaches OBSTETRICS AND GYNECOLOGY o Cesarean Delivery o Hysterectomy, Abdominal o Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted o Hysterectomy, Vaginal o Laparoscopic Gynecological Surgery Including Myomectomy, Oophorectomy, and Salpingectomy o Laparotomy for Gynecological 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 o Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, Single Level o Lumbar Diskectomy, Foraminotomy, Laminotomy, Multiple Levels o Lumbar Fusion o Wrist Fracture, Open Treatment THORACIC SURGERY AND PULMONARY DISEASE o Lung Transplant UROLOGY o Prostatectomy, Transurethral, Alternatives to Standard Resection o Renal Transplant CUSTOMIZATIONS - GENERAL RECOVERY GUIDELINES (GRG) Issue Date: December 10, 2009 R3 Page 2 of 13

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 21, 2009 MPTAC) General Recovery Guidelines (GRG) o Inpatient Palliative Care Criteria CUSTOMIZATION HISTORY CUSTOMIZATIONS BACKGROUND INFORMATION Types of s: 1. s to Milliman Care Guidelines clinical indications based on integration with our medical policy and clinical UM guidelines. 2. s to Milliman Care Guidelines clinical indications with changes to the original Milliman criteria which includes adding or revising appropriateness criteria. 3. s 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), listing our related medical policies or clinical UM guidelines under the Related Guidelines section, or other changes to Milliman Care Guidelines, e.g., revision to Alternatives for Procedure. Review and Approval of s: 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. Issue Date: December 10, 2009 R3 Page 3 of 13

CUSTOMIZATIONS INPATIENT AND SURGICAL CARE GUIDELINES Behavioral Health Behavioral Health (BH) 13 th Ed: All BH guidelines Behavioral Health (BH) 13 th Ed: Delirium Behavioral Health (BH) 13 th Ed: Substance Abuse, Dependence, or Withdrawal NOTE: The Behavioral Health Guidelines (ISC and GRG) were removed (with the exception of those ISC guidelines noted as reinstated) Continue to reinstate guideline for Delirium 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 Detoxification Without Extended On-Site Monitoring (Office Based), Substance Abuse Outpatient Detoxification With Extended On-Site Monitoring, 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 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 Goal Length of Stay to indicate Ambulatory or 1 day rather than Ambulatory o For electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) see the following: SURG.00033 Implantable Cardioverter-Defibrillator (ICD); 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: o 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) Listed related medical policy and clinical UM guideline under Related Guidelines Issue Date: December 10, 2009 R3 Page 4 of 13

Cardiology - Supraventricular Arrhythmias Cardiovascular (CV) Surgery Aortic Aneurysm, Abdominal, Endovascular Repair Aortic Aneurysm, Abdominal, Repair or Excision with Graft Replacement Cardiac Septal Defect: Atrial, Transcatheter Closure Carotid Endarterectomy Coronary Artery Bypass Graft (CABG) Coronary Artery Bypass Graft, Minimally Invasive Direct (MIDCAB) Heart Transplant o For abdominal aortic aneurysm, endovascular repair, see SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms o For transcatheter closure of cardiovascular defects, see SURG.00032 Transcatheter Closure of Cardiovascular Defects Revised Alternatives to Procedure, carotid angioplasty and stent, footnote G, to indicate: 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 E, revised to indicate: For information on transmyocardial laser revascularization, see SURG.00019 Transmyocardial Revascularization o For enhanced external counterpulsation, footnote F, 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 G, revised to indicate: For information on transmyocardial laser revascularization, see SURG.00019 Transmyocardial Revascularization o For enhanced external counterpulsation, footnote H, revised to indicate: For information on enhanced external counterpulsation in the outpatient setting, see MED.00010 Enhanced External Counterpulsation (EECP) in the Outpatient Setting o For heart transplantation, see TRANS.00026 Heart/Lung Transplantation; TRANS.00033 Heart Transplantation Issue Date: December 10, 2009 R3 Page 5 of 13

Patent Ductus Arteriosus, Transcatheter Coil Occlusion Sympathectomy by Thoracoscopy or Laparoscopy Included note under Clinical Indications for Procedure: o For additional information on treatment of hyperhidrosis, see MED.00032 Treatment of Hyperhidrosis Common Complications and Conditions Preoperative Days 13 th Ed: Preoperative Days Included an additional indication for Inpatient Stay Before Elective Surgery: o 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 Endocrinology Endocrinology - Parathyroidectomy Endocrinology - Thyroidectomy Gastroenterology Gastroenterology - Liver Disease Complications General Surgery Cholecystectomy by Laparoscopy Gastric Restrictive Procedure with Gastric Bypass Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy Gastric Restrictive Procedure without Gastric Bypass Revised Clinical Indications for Admission to Inpatient Care: o For acute hepatitis, revised bilirubin greater than 20 mg/dl (342 micromoles/l) to indicate bilirubin greater than 10 mg/dl (171 micromoles/l) o For gastric restrictive procedure with gastric bypass, see SURG.00024 Surgery for Clinically Severe Obesity o For gastric restrictive procedure with gastric bypass by laparoscopy, see SURG.00024 Surgery for Clinically Severe Obesity o For gastric restrictive procedure without gastric bypass, see SURG.00024 Surgery for Clinically Severe Obesity Issue Date: December 10, 2009 R3 Page 6 of 13

Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy Liver Transplant Mastectomy, Modified Radical Mastectomy, Partial (Lumpectomy) with Axillary Lymphadenectomy Mastectomy, Modified Radical, with Insertion of Breast Prosthesis or Tissue Expander Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap and Microvascular Anastomosis o For gastric restrictive procedure without gastric bypass by laparoscopy, see SURG.00024 Surgery for Clinically Severe Obesity o For liver transplantation, see TRANS.00008 Liver Transplantation o For prophylactic mastectomy, see SURG.00063 Prophylactic Mastectomy o For prophylactic mastectomy, see SURG.00063 Prophylactic Mastectomy o For prophylactic mastectomy, see SURG.00063 Prophylactic Mastectomy o For prophylactic mastectomy, see SURG.00063 Prophylactic Mastectomy Neonatal Level of Care Guidelines Issue Date: December 10, 2009 R3 Page 7 of 13

Neonatal Level of Care Guidelines 13 th Ed: 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: o 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 Included note under Clinical Indications for Admission to Inpatient Care: o See Related Guidelines section for additional medical policy or clinical UM guidelines related to the treatment of headaches For Emergent Neuroimaging/LP Criteria List, added notation to see also CG-RAD-11 CT/MRI Brain and Head Obstetrics and Gynecology Cesarean Delivery Hysterectomy, Abdominal Hysterectomy, Laparoscopic Title change to: applicable included under both Clinical Indications section and Goal Length of Stay (GLOS) sections o For prophylactic hysterectomy, see SURG.00058 Prophylactic Bilateral Oophorectomy and Prophylactic Hysterectomy o For uterine leiomyomata ("fibroids ), abnormal uterine bleeding unresponsive to conservative management (eg, hormonal treatment), added when conservative treatment is appropriate o For abnormal uterine bleeding, removed requirement of conservative surgical management with 1 or more of the following: (a) Curettage, (b) Hysteroscopy, (c) Endometrial ablation o For pelvic relaxation, persistence of symptoms despite nonsurgical therapy such as pelvic muscle rehabilitation, added a note that Kegel exercises are considered a form of nonsurgical therapy such as pelvic muscle rehabilitation o For endometriosis, pelvic pain despite treatment with progestins or gonadotropin-releasing hormone (GnRH) agonists, added a note that oral contraceptives (OCPs) are considered a form of progestin therapy o For chronic pelvic inflammatory disease, removed requirement of no improvement with lysis of adhesions as indicated o For pelvic pain, laparoscopy negative for specific gynecologic and nongynecologic etiologies, added other than adenomyosis o For pelvic pain, removed requirement of comprehensive evaluation (chronic pain, mental health) performed as indicated Added reference Under Related Guidelines, title change from Hysterectomy, Laparoscopic to indicate Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted Title changed from Hysterectomy, Laparoscopic to indicate: Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted o For prophylactic hysterectomy, see SURG.00058 Prophylactic Bilateral Oophorectomy and Issue Date: December 10, 2009 R3 Page 8 of 13

Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopicallyassisted Hysterectomy, Vaginal Laparoscopic Gynecological Surgery Including Myomectomy, Oophorectomy, and Salpingectomy Prophylactic Hysterectomy o For uterine leiomyomata ("fibroids ), abnormal uterine bleeding unresponsive to conservative management (eg, hormonal treatment), added when conservative treatment is appropriate o For abnormal uterine bleeding, removed requirement of conservative surgical management with 1 or more of the following: (a) Curettage, (b) Hysteroscopy, (c) Endometrial ablation o For pelvic relaxation, persistence of symptoms despite nonsurgical therapy such as pelvic muscle rehabilitation, added a note that Kegel exercises are considered a form of nonsurgical therapy such as pelvic muscle rehabilitation o For endometriosis, pelvic pain despite treatment with progestins or gonadotropin-releasing hormone (GnRH) agonists, added a note that oral contraceptives (OCPs) are considered a form of progestin therapy o For chronic pelvic inflammatory disease, removed requirement of no improvement with lysis of adhesions as indicated o For pelvic pain, laparoscopy negative for specific gynecologic and nongynecologic etiologies, added other than adenomyosis o For pelvic pain, removed requirement of comprehensive evaluation (chronic pain, mental health) performed as indicated Added reference o For prophylactic hysterectomy, see SURG.00058 Prophylactic Bilateral Oophorectomy and Prophylactic Hysterectomy o For uterine leiomyomata ("fibroids ), abnormal uterine bleeding unresponsive to conservative management (eg, hormonal treatment), added when conservative treatment is appropriate o For abnormal uterine bleeding, removed requirement of conservative surgical management with 1 or more of the following: (a) Curettage, (b) Hysteroscopy, (c) Endometrial ablation o For pelvic relaxation, persistence of symptoms despite nonsurgical therapy such as pelvic muscle rehabilitation, added a note that Kegel exercises are considered a form of nonsurgical therapy such as pelvic muscle rehabilitation o For endometriosis, pelvic pain despite treatment with progestins or gonadotropin-releasing hormone (GnRH) agonists, added a note that oral contraceptives (OCPs) are considered a form of progestin therapy o For chronic pelvic inflammatory disease, removed requirement of no improvement with lysis of adhesions as indicated o For pelvic pain, laparoscopy negative for specific gynecologic and nongynecologic etiologies, added other than adenomyosis o For pelvic pain, removed requirement of comprehensive evaluation (chronic pain, mental health) performed as indicated Added reference Under Related Guidelines, title change from Hysterectomy, Laparoscopic to indicate Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted o For prophylactic oophorectomy, see SURG.00058 Prophylactic Bilateral Oophorectomy and Prophylactic Hysterectomy Revised Alternatives to Procedure: o For uterine artery embolization for leiomyomata, see CG-SURG-28 Transcatheter Uterine Artery Embolization Under Related Guidelines, title changed from Hysterectomy, Laparoscopic to indicate Hysterectomy, Laparoscopic; Hysterectomy, Vaginal, Laparoscopically-assisted Issue Date: December 10, 2009 R3 Page 9 of 13

Laparotomy for Gynecological Surgery Including Myomectomy, Oophorectomy, and Salpingectomy 13h Ed: Preterm Labor, Threatened Vaginal Delivery OB/GYN - Vaginal Delivery, Operative o For prophylactic oophorectomy, see SURG.00058 Prophylactic Bilateral Oophorectomy and Prophylactic Hysterectomy Revised Alternatives to Procedure: o For uterine artery embolization for leiomyomata, see the following: CG-SURG-28 Transcatheter Uterine Artery Embolization Listed related medical policy and clinical UM guideline under Related Guidelines Revised Clinical Indications for Admission to Inpatient Care: o Included placenta previa with vaginal bleeding under clinical indications for admission to inpatient care. Added reference Orthopedics Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy Knee Arthroplasty Knee Arthroscopy Lumbar Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, Single Level Lumbar Diskectomy, Foraminotomy, Laminotomy, Multiple Levels Lumbar Fusion Listed related medical policy and clinical UM guideline under Related Guidelines Included note under Clinical Indications for Procedure: o For bicompartmental knee arthroplasty, see SURG.00105 Bicompartmental Knee Arthroplasty o For debridement, added language for debridement of an arthritic joint, with or without lavage o Included two additional indications for debridement of an arthritic joint, with or without lavage: (a) chondral defects amenable to surgical correction, and (b) meniscal defects amenable to surgical correction Listed related clinical UM guidelines under Related Guidelines Removed: Issue Date: December 10, 2009 R3 Page 10 of 13

Wrist Fracture, Open Treatment Lumbar spinal stenosis[b] with ALL of the following(1)(11)(12): o Associated lumbar spondylolisthesis o 1 or more of the following: Progressive or severe symptoms of neurogenic claudication Back pain, neurogenic claudication symptoms, or radicular pain associated with ALL of the following: Significant functional impairment Listhesis demonstrated on plain x-rays Central, lateral recess or foraminal stenosis demonstrated on imaging (eg, MRI, CT, myelography) Failure of at least 3 months of conservative care Spondylolysis[C] with 1 or more of the following(13)(15)(16): o Progressive spondylolisthesis with neurologic compromise o Spondylolisthesis with 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 conservative care Added: 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[b] Spondylolisthesis[C] with 1 or more of the following: o Progressive deformity or neurologic compromise o Pediatric (age <=18) patients with high-grade (ie, 50% or more anterior slippage) spondylolisthesis demonstrated on x-ray o 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 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) Added indications for when a lumbar fusion is considered not medically necessary. o 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 Thoracic Surgery and Pulmonary Disease Thoracic Surgery and Pulmonary Disease - Lung Transplant o For Lung Transplant see the following: TRANS.00009 Lung and Lobar Transplantation TRANS.00026 Heart/Lung Transplantation Urology Issue Date: December 10, 2009 R3 Page 11 of 13

Urology - Prostatectomy, Transurethral, Alternatives to Standard Resection Urology - Renal Transplant Included note under Clinical Indications for Procedure: o 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 o For renal transplant, see CG-TRANS-02 Kidney Transplantation Listed related clinical UM guidelines under Related Guidelines CUSTOMIZATIONS GENERAL RECOVERY GUIDELINES (GRG) General Recovery Guideline (GRG) Behavioral Health Behavioral Health (BH) 13 th Ed: 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 Section 13 th Ed: Inpatient Palliative Care Criteria May 21, 2009 MPTAC review: Added section on Alternatives to Admission Added reference for Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual, Ch 9 Coverage of hospice services under hospital insurance Added section on Related Guidelines Inpatient Palliative Care Criteria, 13 th edition, approved without customization. Archive CG-MED-25 Hospice, Inpatient Setting when Milliman Care Guidelines 13 th edition is effective. Problem Oriented GRG Problem Oriented 13 th Ed: Medical Oncology GRG Included note under Clinical Indications for Admission to Inpatient Care: Criteria Detail: o For radioactive implant treatments needing inpatient environment, added note for inpatient admission for radiation therapy for cervical or thyroid cancer, see CG-RAD-19 Inpatient Admission Issue Date: December 10, 2009 R3 Page 12 of 13

General Recovery Guideline (GRG) for Radiation Therapy for Cervical or Thyroid Cancer CUSTOMIZATION HISTORY Date Action Reason 12/10/2009 Release updated document for s to Milliman Care Guidelines 13 th Edition Post document to Internet websites 05/21/2009 Release updated document for s to Milliman Care Guidelines 13 th Edition 03/09/2009 Release document for s to Milliman Care Guidelines 13 th Edition Updated document for s to Milliman Care Guidelines 13 th Edition. See Index for customizations recent updates (May 21, 2009 MPTAC). New document for s to Milliman Care Guidelines 13 th Edition Issue Date: December 10, 2009 R3 Page 13 of 13