Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Georgia Form

State Clinical Guideline
number Clinical Guideline name Clinical Guideline category Date adopted by GA Special notes GA CG-ANC-04 Ambulance Services: Air and Water Ancillary/Miscellaneous 3/11/2008 GA CG-ANC-07 Inpatient Interfacility Transfers Ancillary/Miscellaneous 7/1/2019 GA CG-BEH-02 Adaptive Behavioral Treatment Behavioral Health 11/18/2013 Effective 6/1/2024 transitioned to MCG guidelines GA CG-BEH-14 Intensive In-home Behavioral Health Services Behavioral Health 7/1/2016 GA CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome Behavioral Health 6/28/2018 GA CG-DME-10 Durable Medical Equipment Durable Medical Equipment 5/1/2025 GA CG-DME-31 Powered Wheeled Mobility Devices Durable Medical Equipment 1/1/2011 GA CG-DME-45 Ultrasound Bone Growth Stimulation Durable Medical Equipment 9/20/2018 GA CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting Durable Medical Equipment 3/1/2019 GA CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Genetics 4/24/2019 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies Genetics 9/4/2019 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status Genetics 9/4/2019 4/1/2024 Transition to CarelonMBM guidelines Anthem Blue Cross and Blue Shield
GA Clinical Criteria Adoption 11/1/2025 NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered ‘Adopted’ for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes. Anthem Clinical Guidelines adopted by GA and reviewed by Anthem Blue Cross and Blue Shield Page 1 of 5 GABCBS-CM-096557-25 November 2025

GA CG-GENE-13 Genetic Testing for Inherited Diseases Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-16 BRCA Genetic Testing Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-18 Genetic Testing for TP53 Mutations Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing Genetics 2/5/2020 4/1/2024 Transition to CarelonMBM guidelines GA CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment Genetics 4/7/2021 4/1/2024 Transition to CarelonMBM guidelines GA CG-LAB-13 Skin Nerve Fiber Density Testing Laboratory 6/28/2018 GA CG-MED-19 Custodial Care Medicine 1/8/2008 GA CG-MED-26 Neonatal Levels of Care Medicine 1/8/2008 GA CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting Medicine 3/1/2025 GA CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Medicine 11/1/2018 GA CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins Medicine 8/1/2023 4/1/2025 Transition to CarelonMBM guidelines GA CG-MED-65 Manipulation Under Anesthesia Medicine 10/1/2024 GA CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue Medicine 3/1/2025 GA CG-MED-68 Therapeutic Apheresis Medicine 12/27/2017 GA CG-MED-69 Inhaled Nitric Oxide Medicine 6/28/2018 GA CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) Medicine 3/1/2025 GA CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Medicine 9/20/2018 GA CG-MED-76 Magnetic Source Imaging and Magnetoencephalography Medicine 10/1/2024 GA CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures Medicine 10/1/2022 GA CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems Medicine 3/1/2025 GA CG-MED-81 Ultrasound Ablation for Oncologic Indications Medicine 3/1/2025 3/1/2025 Transition to CarelonMBM GA CG-MED-83 Site of Care: Specialty Pharmaceuticals Medicine 4/24/2019 GA CG-MED-88 Preimplantation Embryo Biopsy Medicine 3/1/2025 GA CG-MED-89 Home Parenteral Nutrition Medicine 11/1/2021 Page 2 of 5

GA CG-MED-97 Biofeedback and Neurofeedback Medicine 6/28/2024 GA CG-MED-98 Parenteral Antibiotics for the Treatment of Lyme Disease Medicine 1/30/2025 Previously MED.00013. CG-MED-99 Intradialytic Parenteral Nutrition Medicine 11/1/2025 GA CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine Medicine 3/6/2025 Previously DME.00011 and CG-SURG-120. GA CG-REHAB-08 Private Duty Nursing in the Home Setting Rehabilitation 1/31/2008 GA CG-SURG-03 Blepharoplasty, Blepharoptosis Repair and Brow Lift Surgery 1/31/2008 GA CG-SURG-09 Temporomandibular Disorders Surgery 3/1/2025 GA CG-SURG-12 Penile Prosthesis Implantation Surgery 8/1/2011 GA CG-SURG-18 Septoplasty Surgery 10/6/2006 GA CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Surgery 1/1/2011 GA CG-SURG-28 Transcatheter Uterine Artery Embolization Surgery 4/1/2012 7/25/2025: Transitioned to CarelonMBM guidelines. GA CG-SURG-29 Lumbar Discography Surgery 4/1/2024 GA CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)
Surgery 3/1/2025 GA CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities Surgery 8/1/2021 4/1/2024 Transitioned to CarelonMBM guidelines. GA CG-SURG-55 Cardiac Electrophysiological Studies (EPS) and Catheter Ablation Surgery 4/1/2024 GA CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver Surgery 12/27/2017 GA CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure Surgery 12/27/2017 4/1/2024 Transition to CarelonMBM guidelines GA CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018 GA CG-SURG-73 Balloon Sinus Ostial Dilation Surgery 6/28/2018 GA CG-SURG-78 Cryosurgical, Radiofrequency, Microwave, or Percutaneous Ethanol Ablation to Treat Solid Tumors in the Liver Surgery 6/28/2018 GA CG-SURG-79 Implantable Infusion Pumps Surgery 6/28/2018 GA CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Surgery 9/20/2018 GA CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids Surgery 9/20/2018 GA CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/2018 GA CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Surgery 9/20/2018 GA CG-SURG-88 Mastectomy for Gynecomastia Surgery 9/20/2018 GA CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia Surgery 9/20/2018 GA CG-SURG-92 Paraesophageal Hernia Repair Surgery 7/1/2019 Page 3 of 5

GA CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction Surgery 7/1/2019 4/1/2025 Transition to CarelonMBM guidelines GA CG-SURG-95 Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence Surgery 3/1/2025 GA CG-SURG-96 Intraocular Telescope Surgery 3/1/2025 GA CG-SURG-97 Cardioverter-Defibrillators Surgery 6/24/2019 4/1/2024 Transition to CarelonMBM guidelines GA CG-SURG-99 Panniculectomy, Abdominoplasty Surgery 5/9/2019 GA CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus Surgery 4/1/2024 GA CG-SURG-105 Corneal Collagen Cross-Linking Surgery 2/5/20/20 GA CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone Surgery 2/5/20/20 GA CG-SURG-117 Balloon Dilation of the Eustachian Tubes Surgery 3/1/2025 GA CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) Surgery 4/10/2024 Previously SURG.00103 GA CG-SURG-119 Treatment of Vericose Veins (Lower Extremities) Surgery 4/10/2024 Previously SURG.00037 GA CG-SURG-120 Vagus Nerve Stimulation Surgery 4/10/2024 Previously SURG.00007 GA CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers Surgery 1/30/2025 Previously MED.00132 GA CG-SURG-125 Canaloplasty Surgery 1/30/2025 Previously SURG.00095 GA CG-SURG-126 Tibial Nerve Stimulation Surgery 11/1/2025 GA CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses Surgery 4/1/2025 Previously SURG.00011 GA CG-SURG-129 Internal Rib Fixation Systems Surgery 7/1/2025 Previously SURG.00120 GA CG-TRANS-02 Kidney Transplantation Transplants 2/26/2008 Carelon Medical Benefits Management Inc. Specialty Pharmacy Drugs NOTE: As of 6/15/2019, non-oncology drugs are reviewed by Anthem Pharmacy Utilization Management (UM) Operations Page 4 of 5

Carelon Medical Benefits Management (MBM) Inc. an independent company providing utilization management services on behalf of the health plan. Determine if preapproval is needed for a GA member by clicking the “Medical Policy, Clinical UM Guidelines, and Preapproval Requirements” link on our provider website or by calling the preapproval phone number printed on the back of the member’s ID card. To submit your request for any of the services below, contact Carelon Medical Benefits Management online via the ProviderPortal at https://guidelines.carelonmedicalbenefitsmanagement.com From the drop-down menu, select GA. You may also call Carelon Medical Benefits Management toll-free at 866-714-1103, Monday – Friday, 8:00 a.m. – 6:00 p.m. ET.
Carelon Medical Benefits Management Inc. provides benefits management for the programs listed below:

> Imaging Level of Care
> Genetic Testing
> Diagnostic Imaging Management
> Cardiovascular Services
> Radiation Therapy Services
> Rehabilitative Services and Site of Care 
> Sleep Therapy
> Outpatient Sleep Testing and Therapy Services
> Oncology Drugs
> Cancer Care Quality Program
> Musculoskeletal (MSK) and Site of Care

Upper Gastrointestinal Endoscopy in Adults, and Site of Care for Certain Surgical Services
For more details on these programs, please visit the Carelon Medical Benefits Management Inc. site at https://guidelines.carelonmedicalbenefitsmanagement.com/
By clicking on the link above, you will be linked to sites created and/or maintained by another, separate entity (“External Site”). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. Note:

• Date Adopted by: this is the original adoption date for the State For more details and information on CUMGs adopted by Anthem Inc., please click below: https://www.anthem.com/provider/policies/ Page 5 of 5