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

Carelon Medical Benefits Management, Inc. is a separate company providing utilization review services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Community Care Health Plan of Nevada, Inc. and Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NV-BCBS-CM-009528-26-S2728 | April 2026

Adopted Clinical Guidelines as of: May 1, 2026

Nevada | Anthem Blue Cross and Blue Shield and HMO Colorado, Inc. (Anthem) | Commercial

Note: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered “Adopted” for that ASO group only and for the specific type of review required.

Additionally, as part of the Pre-Payment Review Program for Commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Nevada Special notes NV CG-ANC-04 Ambulance Services: Air and Water Ancillary/Miscellaneous 4/16/2013

NV CG-ANC-08 Mobile Device-Based Health Management Applications Ancillary/Miscellaneous 8/1/2020

NV CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome Behavioral Health 6/28/2018

NV CG-DME-06 Compression Devices for Lymphedema Durable Medical Equipment 4/1/2026

NV CG-DME-07 Augmentative and Alternative Communication (AAC) Devices with Digitized or Synthesized Speech Output Durable Medical Equipment 4/1/2024

NV CG-DME-10 Durable Medical Equipment Durable Medical Equipment 7/1/2013

NV CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Durable Medical Equipment 3/1/2023

NV CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs — Ultra Lightweight Durable Medical Equipment 4/1/2024

Adopted Clinical Guidelines as of: May 1, 2026 Page 2 of 5

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Nevada Special notes NV CG-DME-43 High Frequency Chest Compression Devices for Airway Clearance
Durable Medical Equipment 5/1/2018

NV CG-DME-45 Ultrasound Bone Growth Stimulation Durable Medical Equipment 9/20/2018

NV CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting Durable Medical Equipment 12/1/2019

NV CG-DME-57 Lower Extremity Pressure Gradient Compression Stockings Durable Medical Equipment 11/1/2025

NV CG-DME-59 Self-Operated Spinal Unloading Devices Durable Medical Equipment 4/1/2026

NV CG-LAB-13 Skin Nerve Fiber Density Testing Laboratory 1/1/2023

NV CG-MED-26 Neonatal Levels of Care Medicine 8/12/2013

NV CG-MED-37 Intensive Programs for Pediatric Feeding Disorders Medicine 4/1/2017

NV CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Medicine 11/1/2018

NV CG-MED-65 Manipulation Under Anesthesia
Medicine 12/27/2017

NV CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue Medicine 12/27/2017

NV CG-MED-68 Therapeutic Apheresis Medicine 12/27/2017

NV CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Medicine 9/20/2018

NV CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Medicine 1/1/2026

NV CG-MED-78 Anesthesia Services for Interventional Pain Management Procedures Medicine 10/1/2024

NV CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing System Medicine 1/1/2019

NV CG-MED-81 Ultrasound Ablation for Oncologic Indications Medicine 5/1/2023

NV CG-MED-83 Site of Care: Specialty Pharmaceuticals Medicine 4/23/2019

NV CG-MED-89 Home Parenteral Nutrition Medicine 11/1/2021

NV CG-MED-97 Biofeedback and Neurofeedback Medicine 12/1/2024

NV CG-MED-99 Intradialytic Parenteral Nutrition Medicine 11/1/2025

NV CG-MED-100 Surface Electrical Stimulation Devices for Headache and Migraine Medicine 11/1/2025

NV CG-MED-101 Home Hospice Medicine 11/1/2025

NV CG-MED-102 Dichoptic Digital Therapy for Amblyopia Previously Titled: Digital Therapy Devices for Treatment of Amblyopia Medicine 11/1/2025

NV CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices Orthotics/Prosthetics 4/15/2014

NV CG-RAD-29 X-rays for Low Back Pain Radiology 1/1/2026

NV CG-RAD-30 Non-Obstetrical Transvaginal Ultrasonography Radiology 4/1/2026

NV CG-RAD-31 Three-Dimensional (3-D) Rendering of Imaging Studies Radiology 4/1/2026

Adopted Clinical Guidelines as of: May 1, 2026 Page 3 of 5

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Nevada Special notes NV CG-RAD-32 Bone Mineral Density Testing Measurement Radiology 4/1/2026

NV CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
Rehabilitation 4/16/2013

NV CG-REHAB-08 Private Duty Nursing in the Home Setting Rehabilitation 4/16/2013

NV CG-SURG-12 Penile Prosthesis Implantation
Surgery 1/8/2013

NV CG-SURG-27 Gender Affirming Surgery Surgery 10/9/2012

NV CG-SURG-29 Lumbar Discography
Surgery 5/13/2013

NV CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver Surgery 12/27/2017

NV CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018

NV CG-SURG-79 Implantable Infusion Pumps
Surgery 6/28/2018

NV CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
Surgery 9/20/2018

NV CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids
Surgery 9/20/2018

NV CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/2018

NV CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Surgery 1/1/2023

NV CG-SURG-88 Mastectomy for Gynecomastia
Surgery 9/20/2018

NV CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
Surgery 8/29/2018

NV CG-SURG-92 Paraesophageal Hernia Repair Surgery 4/1/2024

NV CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Surgery 3/21/2019

NV CG-SURG-99
Panniculectomy and Abdominoplasty Surgery 5/9/2019

NV CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus Surgery 9/4/2019

NV CG-SURG-105 Corneal Collagen Cross-Linking Surgery 2/5/2020

NV CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone Surgery 2/5/2020

NV CG-SURG-108 Stereotactic Radiofrequency Pallidotomy Surgery 4/15/2020

NV CG-SURG-118 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) Surgery 10/1/2024

NV CG-SURG-120 Vagus Nerve Stimulation Surgery 10/1/2024

NV CG-SURG-125 Canaloplasty Surgery 9/1/2025

NV CG-SURG-126 Tibial Nerve Stimulation Surgery 11/1/2025

NV CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses Surgery 11/1/2025

NV CG-SURG-129 Internal Rib Fixation Systems Surgery 1/1/2026

Adopted Clinical Guidelines as of: May 1, 2026 Page 4 of 5

State Clinical Guideline number
Clinical Guideline name

Original implementation date by Nevada Special notes NV CG-TRANS-02 Kidney Transplantation Transplants 1/8/2013

• Original implementation date by state — This is the original implementation date by the health plan. Third-party criteria adopted: The health plan may use guidelines developed by third parties to perform utilization management services for certain procedures for certain health plan members. Carelon Medical Benefits Management To view Carelon Medical Benefits Management Guidelines, please visit the Carelon Specialty Health® site that contains links to Anthem programs: https://guidelines.carelonmedicalbenefitsmanagement.com. You may also call Carelon Medical Benefits Management: 877-291-0366, 9 a.m. to 7 p.m. CT, Monday through Friday. The health plan's implementation of Carelon Medical Benefits Management Guidelines is listed below. By clicking on the Carelon Medical Benefits Management link above, you will be linked to site(s) 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.

  Carelon Medical Benefits Management Health plan implementation date NV Carelon Medical Benefits Management Carelon Site of Service Medical Necessity Reviews for upper and lower endoscopy procedures 6/1/2020 NV Carelon Medical Benefits Management Carelon Rehabilitative Services 4/1/2020 NV Carelon Medical Benefits Management Carelon Clinical Appropriateness Guidelines for Radiology (Adult & Pediatric)
  9/1/2017 NV Carelon Medical Benefits Management Carelon Clinical Appropriateness Guidelines for Sleep Disorder Management
  11/1/2012 NV Carelon Medical Benefits Management Carelon Musculoskeletal Clinical Appropriateness Guidelines: Spine Surgery, Joint Surgery, and Interventional Pain Management
  1/1/2019 NV Carelon Medical Benefits Management Carelon Level of Care Guidelines for Musculoskeletal Surgery and Procedures
  1/1/2019 NV Carelon Medical Benefits Management Carelon Preoperative Admission Guidelines for Musculoskeletal Surgery and Procedures
  1/1/2019 NV Carelon Medical Benefits Management Carelon Cardiology Clinical Appropriateness Guidelines: Advanced Imaging of the Heart, Arterial Ultrasound, Percutaneous Coronary Intervention, and Diagnostic Coronary Angiography
  3/1/2016 NV Carelon Medical Benefits Management Carelon Radiation Oncology Clinical Appropriateness Guidelines: Radiation Oncology includes brachytherapy, intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS)
  11/1/2012 NV Carelon Medical Benefits Management Carelon Sleep Clinical Appropriateness Guidelines 11/1/2012

Adopted Clinical Guidelines as of: May 1, 2026 Page 5 of 5

Carelon Medical Benefits Management Health plan implementation date NV Carelon Medical Benefits Management Rehabilitation Clinical Site of Care 8/1/2021 NV Carelon Medical Benefits Management Carelon Musculoskeletal Program Site of Care 1/1/2022

MCG Care Guidelines NV Anthem licenses and uses MCG Care Guidelines to guide UM decisions for some health plans. This may include, but is not limited to, decisions involving precertification, inpatient review, level of care, discharge planning, and retrospective review. The MCG Care Guidelines licensed include:
(1) Inpatient and Surgical Care (ISC) (2) General Recovery Care (GRG) (3) Recovery Facility Care (RFC) (4) Chronic Care (CC) (5) Behavioral Health Care Guidelines (BHG) Notes: For a complete listing of Medical Policies and Clinical UM Guidelines, please go to: Anthem Provider site > select your state> scroll down page, select See Policies and Guidelines.