OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. M issouri Care, Inc. ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc.

Obstetric Ultrasound (including 3D, 4D, Standard, Limited, Comprehensive, Targeted and Follow-Up)

WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc.

Applies to AZ, HI, MO, NJ and SC only. Policy Number: HS-002

WellCare of Ohio, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc.

Original Effective Date: 3/1/2007 Revised Date(s): 3/13/2008; 6/4/2009; 6/18/2010; 8/12/2011; 5/3/2012; 8/9/2013

DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benef it Plan, Ev idence of Cov erage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may c ontain specif ic exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the inf ormation contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively t o the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benef it determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/Providers/CCGs for list of c urrent LOBs.

APPLICATION STATEMENT The application of the Clinical Cov erage Guideline is subject to the benef it determinations set f orth by the Centers f or Medicare and Medicaid Serv ices (CMS) National and Local Cov erage Determinations and state-specif ic Medicaid mandates, if any .

OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

BACKGROUND Sixty to seventy percent of pregnant women in the United States receive an ultrasound examination during their pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends that in low-risk pregnancies use of ultrasound generally be reserved for answering spec ific medical questions, rather than as a routine offering to all women. However, many health care providers recommend that one ultrasound examination, usually done between 16 and 20 weeks of pregnancy, be included as a routine part of prenatal care. The us e of ultrasonography to test for potential fetal abnormalities, confirm the site of pregnancy within the uterus, and determine gestational age is considered the standard of care. Types of Examinations (ACOG, 2009) ACOG uses the terms “standard”, “limited”, and “specialized” to describe various types of ultrasound examinations performed during the second or third trimesters. Although the standard and limited examinations are defined by their components, the specialized examination is defined by the indicat ions for the exam, that is, the circumstances that suggest a more thorough ultrasound exam is needed. 3D and 4D Ultrasound Three-dimensional (3D) ultrasound (US) is used to create both a surface image of the fetus in utero and crosssectional images from any angle; images of extra-fetal and maternal structures can be created in a similar manner. In constructing the 3D US image, the software automatically records and stores the image as part of the process. The stored virtual 3D US image can be rotated for different surface views and cross sections from angles not available with two-dimensional (2D) US. This has potential use in detecting and diagnosing abnormalities in maternal and extra-fetal structures as well as in the developing fetus. Four-dimensional (4D) US, or real-time 3D US, can create many images per second, so that fetal motion can be observed in three dimensions. While use of 3D US and 4D US has been commercialized to create non-diagnostic “keepsake” images, the value of these detailed images for informing parental decision making and pregnancy and postpartum management is currently under investigation. Three-dimensional (3D) ultrasound (US) is achieved by stacking together multiple 2D US images or cross sections in the manner of tomography. Computer software converts these multiple 2D US images into a virtual 3D US volume. The pixels of the 2D US image (the smallest piece of digital information) are transformed into voxels of the 3D US image. The 2D US images can be acquired by moving the probe or scanner perpendicular to the 2D US planes or in a fanlike pattern, methods typically used for trans-abdominal (TA) images, or by rotation, used for transvaginal (TV) images. The appropriate scanner motion can be motorized, or can be done freehand, with a positional marker that synchronizes the 2D US planes. Entirely freehand acquisition can also be done, but this method is not precise enough for carrying out measurements. A single scan of the complete volume can take a few seconds for highest spatial resolution, but the latest instruments can carry out 20 or more scans per second for 4D US motion studies. A cine-loop capability allows repeated viewing of real-time motion. The virtual volume is recorded and stored in a computer. The information can be transferred to hard disks or transported electronically to distant locations. Although the volume is acquired in a matter of seconds, it is available for manipulation and study at length (Hayes, 2006). Standard Examination A standard exam is performed during the second or third trimester of pregnancy. ACOG (2009) states that fetal anatomy can be assessed adequately after approximately 16-20 weeks of gestation. A more detailed fetal anatomic examination may be necessary if an abnormality or suspected abnormality is found on the standard examination. If a trans-abdominal examination is not definitive or conclusive, a transvaginal examination is indicated. Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

Limited Examination In most cases, a limited examination is appropriate only when the patient has had a prior complete examination. A limited examination is performed when a specific question requires investigation. The request for limited ultrasound must be accompanied by a specific reason that documents medical necessity (i.e. no fetal movement felt by patient; vaginal bleeding episode; questionable breech or presentation other than cephalic on pelvic exam, guidance for amniocentesis or CVS by abdominal or vaginal route). Specialized Examination (Detailed or Targeted Anatomic Examination) ACOG (2009) stated that a detailed or targeted anatomic examination may be necessary when an anomaly is suspected on the basis of history, biochemical abnormalities or clinical evaluation, or suspicious results from either the limited or standard ultrasound examination. The Society for Maternal-Fetal Medicine (SMFM) (2004) stated that a fetal ultrasound with detailed anatomic examination is not necessary as a routine scan for all pregnancies; the scan is necessary for a known or suspected fetal anatomic or genetic abnormality. The SMFM stated that the performance of this scan is expected to be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal abnormalities. SMFM has also determined that no more than one fetal ultrasound with detailed anatomic examination is necessary per pregnancy, per practice, when medically necessary (SMFM, 2004). Once this detailed fetal anatomical exam is done, a second one should not be performed unless there are extenuating circumstances with a new diagnosis. The SMFM has stated that it is appropriate to repeat the detailed fetal anatomical ultrasound examination when a patient is seen by another maternal-fetal medicine specialist practice for a second opinion on a fetal anomaly, or if the patient is referred to a tertiary center in anticipation of delivering an anomalous fetus at a hospital with specialized neonatal capabilities. A focused ultrasound assessment is sufficient for follow-up to provide a reexamination of a specific organ or system known or suspected to be abnormal, or when doing a focused assessment of fetal size by measuring the bi -parietal diameter, abdominal circumference, femur length, or other appropriate measurements (SMFM, 2004). An ultrasound without detailed anatomic examination is appropriate for a fetal maternal evaluation of the number of fetuses, amniotic/chorionic sacs, survey of intracranial, spinal and abdominal anatomy, evaluation of a 4-chamber heart view, assessment of the umbilical cord insertion site, assessment of amniotic fluid volume, and evaluation of maternal adenexa when visible and appropriate (SMFM, 2004). Other specialized examinations include fetal Doppler, biophysical profile, fetal echocardiography, or additional biometric studies. For example, a fetal Doppler examination would be appropriate if Intrauterine Growth Restriction (IUGR) is diagnosed. Specialized examinations are performed by an operator with experience and expertise in such ultrasonography who determines the components of the examination on a case-by-case basis (ACOG, 2009). Position Statements ACOG (2009) states that ultrasonography is an accurate method of determining gestational age, fetal number, viability and placental location. In addition, ACOG endorses the “prudent use” of ultrasonography and discouraging its non-medical use.

Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

POSITION STATEMENT Applies to AZ, HI, MO, NJ and SC only. Use of three-dimensional and four-dimensional ultrasound techniques are considered NOT medically necessary for all indications. The following types of obstetric ultrasound are considered medically necessary for the following indications: A. CPT 76801 Limited OB Ultrasound (< 14 weeks gestation) 76802+ each additional gestation CPT 76805 Standard Ultrasound (> 14 weeks gestation) 76810+ each additional gestation Note: Generally performed one time during current pregnancy

Indications 1. to confirm the presence of an intrauterine pregnancy vs. ectopic pregnancy 2. to define the cause of vaginal bleeding 3. to evaluate pelvic pain 4. to estimate gestational age 5. to diagnose or evaluate multiple gestations 6. to confirm cardiac activity after failed attempt with portable Doppler 7. as an adjunct to chronic villous sampling (CVS) 8. to evaluate suspected hydatidiform mole B. CPT 76811 Comprehensive/Targeted OB Ultrasound (> 14 weeks gestation) 76812+ each additional gestation Note: Generally performed one time during current pregnancy unless there is documentation justifying a repeat procedu re Note: Will be covered if performed by a registered diagnostic medical sonographer (RDMS) under direct supervision by a physic ian with specialized training or experience in the subject including a perinatologist and a pediatric cardiologist

Indications 1. suspected fetal anomaly or documented marker for aneuploidy during a standard examination (76805) 2. IUGR (EFW < 10%tile growth), elevated maternal serum AFP, abnormal first trimester screen or multiple marker screen (MMS) 3. polyhydramnios (AFI) > 24 cm or a single pocket of fluid at least 8 cm in depth 4. 2-vessel umbilical cord detected at standard OB ultrasound 5. fetal cardiac arrhythmias 6. significant exposure to drugs or chemicals which are known or suspected teratogens in the first trimester 7. exposure to radiation >5 rads in the first trimester 8. finding of pyelectasis on standard OB ultrasound 9. abnormal fetal karyotype 10. advanced maternal age (age 35 and above at time of delivery) 11. multiple gestation 12. other specified viral, infectious and parasitic diseases complicating pregnancy 13. congenital cardiovascular disorders complicating pregnancy 14. hereditary disease in family FIRST DEGREE PARENT possibly affecting fetus 15. Rh isoimmunization and/or isoimmunization from other and unspecified blood-group incompatibility 16. diabetes mellitus Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

17. unspecified obstetrical trauma 18. oligohydramnios (AFI < 5cm or the absence of a fluid pocket 2 cm in depth) C. CPT 76815 Limited OB Ultrasound (> 14 weeks gestation) 76816 Follow-Up OB Ultrasound (> 14 weeks gestation) Indications for a Limited OB Ultrasound 1. 2. 3. 4. 5. 6. 7. 8. 9.

no fetal movement or decreased fetal movement > 24 weeks gestation vaginal bleeding verifying fetal presentation in patient who is in labor outside of the hospital or >35 weeks gestation pelvic pain in pregnancy assessment of amniotic fluid volume in cases of oligohydramnios (AFI < 5cm or the absence of a fluid pocket 2 cm in depth) and polyhydramnios (AFI) > 24 cm or a single pocket of fluid at least 8 cm in depth placental localization in cases of suspected previa evaluation of certain placental abnormalities (abruption) follow-up of growth of uterine fibroids (submucosal/intramural interfering with intrauterine growth) patients with uncertain dates

Indications for a follow-up OB ultrasound 1. 2. 3. 4.

serial growth assessment in cases of documented IUGR (frequency no less than evey 3 weeks) size/dates discrepancy (small for gestational age fetus, large for gestational age fetus) follow-up of detected fetal structural abnormalities follow-up by a MFM of poorly visualized fetal anatomic structures from a previous standard or targeted ultrasound examination 5. multiple gestation 6. maternal medical condition associated with risk of poor fetal growth with size dates discordance (hypertension, chronic renal disease, connective tissue disorder, diabetes mellitus ( uncontrolled pregestational or gestational), antiphospholipid antibody syndrome, inflammatory bowel disease, sever malnutrition, hyperthyroidism) CODING Covered CPT®* Codes 76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester ( or = 14 weeks 0 days), transabdominal approach; each additional gestation +(List separately in addition to code for primary procedure)

76811 76812+

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation +(List separately in addition to code for primary procedure)

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses

Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

HCPCS Codes - No applicable codes ICD-9-CM Procedure Code 88.78 Diagnostic Ultrasound of gravid uterus Draft 2013 ICD-10-PCS Codes BY49ZZZ - B94GZZZ Imaging, Fetus/Obstetrical, Ultrasonography

Covered ICD-9-CM Diagnosis Codes 640.83 640.93 641.03 641.13 641.23 641.33 641.83 642.03 642.13 642.23 642.73 647.63 647.83 648.03 648.33 648.53 648.83 648.93 651.03 651.13 651.23 651.33 651.43 651.53 652.03 652.13 652.23 652.33 652.43 652.53 652.63 652.73 652.83 653.63 653.73 654.03 654.13 654.33 654.43 655.03 655.13 655.23

Other specified hemorrhage in early pregnancy; antepartum condition or complication Unspecified hemorrhage in early pregnancy; antepartum condition or complication Placenta Previa w ithout hemorrhage; antepartum condition or complication Placenta Previa w ith hemorrhage; antepartum condition or complication Placental Abruption; antepartum condition or complication Hemorrhage associated w ith coagulation defects; antepartum condition or complication Hemorrhage associated w ith trauma or uterine leiomyoma; antepartum condition or complication Benign Essential Hypertension; antepartum condition or complication Hypertension secondary to renal disease; antepartum condition or complication Other Pre-existing Hypertension; antepartum condition or complication Pre-Eclampsia or eclampsia superimposed on Pre-existing Hypertension; antepartum condition or complication Other viral diseases complicating pregnancy, antepartum condition or complication Other specified infectious and parasitic diseases complicating pregnancy, antepartum condition or complication Diabetes mellitus complicating pregnancy, antepartum condition or complication Drug dependence complicating pregnancy, antepartum condition or complication Congenital cardiovascular disorders complicating pregnancy, antepartum condition or complication Gestational Diabetes; abnormal glucose tolerance; antepartum condition or complication Other Current Conditions; antepartum condition or complication Tw in pregnancy, antepartum condition or complication Triplet pregnancy, antepartum condition or complication Quadruplet pregnancy, antepartum condition or complication Tw in pregnancy w ith fetal loss and retention of one fetus, antepartum condition or complication Triplet pregnancy w ith fetal loss and retention of one or more fetus(es), antepartum condition or complication Quadruplet pregnancy w ith fetal retention of one or more fetus(es), antepartum condition or complication Unstable lie; malposition and malpresentation of the fetus Breech presentation w ithout mention of version converted to cephalic presentation Breech Presentation, unspecified Transverse or oblique presentation; malposition and malpresentation of the fetus Face or brow presentation; malposition and malpresentation of the fetus High head at term; malposition and malpresentation of the fetus Multiple gestations w ith malpresentation of one fetus or more Prolapsed arm malposition or malpresentation of the fetus Compound presentation or other specified malposition or malpresentation Hydrocephalic fetus causing disproportion; antepartum condition or complication Other fetal abnormality causing disproportion; antepartum condition or complication Congenital abnormalities of uterus; antepartum condition or complication Tumors of body of uterus; antepartum condition or complication Retroverted and incarcerated gravid uterus; antepartum condition or complication Other abnormalities in shape or position of gravid uterus and neighboring structures; antepartum condition or complication Central nervous system malformation in fetus; antepartum condition or complication Chromosomal abnormality in fetus; antepartum condition or complication Hereditary disease in family possibly affecting fetus; antepartum condition or complication

Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002 655.33 655.43 655.53 655.63 655.73 655.83 655.93 656.13 656.23 656.53 656.63 657.03 658.03 659.53 659.63 659.73 663.83 665.83 793.6 793.99 795.2 V23.1 V28.3 V28.4 V28.81 V28.9

Suspected damage to fetus from viral disease in the mother; antepartum condition or complication Suspected damage to fetus from other disease in the mother; antepartum condition or complication Suspected damage to fetus from drugs; antepartum condition or complication Suspected damage to fetus from radiation; antepartum condition or complication Decreased fetal movements Other know n or suspected fetal abnormality, not elsew here classified; antepartum condition or complication Unspecified know n or suspected fetal abnormality affecting management of mother, antepartum condition or complication Rhesus isoimmunization complicating pregnancy, antepartum condition or complication Isoimmunization from other and unspecified blood-group incompatibility; antepartum condition or complication Poor fetal grow th complicating pregnancy, antepartum condition or complication Excessive fetal grow th complicating pregnancy; antepartum condition or complication Polyhydramnios complicating pregnancy, antepartum condition or complication Oligohydramnios complicating pregnancy, antepartum condition or complication st Elderly primigravida; 1 pregnancy in a w oman w ho w ill be 34 years of age or older at expected date of delivery; antepartum condition or complication nd Elderly multigravida; 2 or more pregnancy in a w oman w ho w ill be 34 years of age or older at expected date of delivery; antepartum condition or complication Abnormality in fetal heart rate or rhythm; antepartum condition or complication Other umbilical cord complications; antepartum condition or complication Other specified obstetrical trauma; antepartum condition or complication Nonspecific abnormal findings on radiological and other examinations of abdominal area, including retroperitoneum Other nonspecific abnormal findings on radiological and other examinations of body structure Abnormal Karyotype in fetus Pregnancy w ith history of trophoblastic disease; hydatidiform mole Encounter for routine screening for malformation of fetus ultrasound NOS Screening for Fetal Grow th Retardation (IUGR) using ultrasound Encounter for fetal anatomic survey Antenatal screening for abnormalities

Draft ICD-10-CM Diagnosis Codes O20.8 O20.9 O28.3 O28.4 O28.5 O28.8 O44.00 O44.10 O45.001 O46.001 O10.011 O10.111 O10.211 O10.311 O10.411 O10.911 O10.1 O24.011 O30.001 O32.0XX0 O34.01 O35.0XX0 O36.0110 O40.1XX0 O41.01X0

Other hemorrhage in early pregnancy Hemorrhage in early pregnancy, unspecified Abnormal ultrasonic finding on antenatal screening of mother Abnormal radiological finding on antenatal screening of mother Abnormal chromosomal and genetic finding on antenatal screening of mother Other abnormal findings on antenatal screening of mother - O44.03 Placenta previa specified as w ithout hemorrhage - O44.13 Placenta previa w ith hemorrhage - O45.93 Premature separation of placenta [abruption placentae] - O46.93 Antepartum Hemorrhage, not elsew here classified - O10.013 Pre-existing essential hypertension complicating pregnancy - O10.113 Pre-existing hypertensive heart disease complicating pregnancy, - O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy - O10.313 Pre-existing hypertensive heart & chronic kidney disease complicating pregnancy, - O10.413 Pre-existing secondary hypertension complicating pregnancy - O10.913 Pre-existing hypertension complicating pregnancy - O11.3 Pre-existing hypertension w ith pre-eclampsia - O24.93 Diabetes mellitus in pregnancy - O30.93 Multiple gestation - O33.9 Maternal care for malpresentation of fetus - O34.93 Maternal care for abnormality of pelvic organs - O35.9XX9 Maternal care for know n or suspected fetal abnormality and damage - O36.93X9 Maternal care for other fetal problems - O40.3XX9 Polyhydramnios - O41.03X9 Oligohydramnios

Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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OBSTETRIC ULTRASOUND (INCLUDING 3D, 4D, STANDARD, LIMITED, COMPREHENSIVE, TARGETED AND FOLLOW-UP) HS-002 O09.11 O09.511 O09.521 O98.511 O98.611 O99.321 O99.411

-

O09.13 O09.513 O09.523 O98.513 O98.613 O99.323 O99.413

Supervision of pregnancy w ith history of ectopic or molar pregnancy Supervision of elderly primigravida Supervision of elderly multigravida Other viral diseases complicating pregnancy Protozoal diseases complicating pregnancy Drug use complicating pregnancy Disease of circulatory system complicating pregnancy

*Current Procedural Term inology (CPT) 2013 Am erican Medical Association: Chicago, IL.®©

REFERENCES Government Agencies, Professional and Medical Organizations 1. American College of Obstetricians and Gynecologists. (2009). ACOG practice bulletin: ultrasonography in pregnancy (no. 101). Obstetrics and Gynecology, 113(2 Pt 1), 451-461. 2. American College of Obstetricians and Gynecologists. (2001). Prenatal diagnosis of fetal chromosomal abnormalities (no. 77). Obstetrics and Gynecology, 97(5 Pt 1): suppl 1-12. 3. Centers for Medicare and Medicaid Services. (2007, May 22). National coverage determination for ultrasound diagnostic procedures (220.5). Retrieved from http://www.cms.hhs.gov/mcd/search.asp 4. Society for Maternal-Fetal Medicine. (2004, May). Coding committee: white paper on ultrasound code 76811. Retrieved from http://www.smfm.org MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date

Action

8/9/2013 5/3/2012 12/1/2011 8/12/2011

   

Reinstated for markets where CareCore is not a vendor. Renamed to include 3D and 4D Ultrasound (HS-109). Retired by MPC; covered by CareCore criteria. New template design approved by MPC. Approved by MPC. No changes.

Clinical Coverage Guideline Original Effective Date: 3/1/2007 - Revised: 3/13/2008, 6/4/2009, 6/18/2010, 8/12/2011, 5/3/2012, 8/9/2013

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