Facet Joint Injections for Spinal Pain – Oxford Clinical ...

UnitedHealthcare? Oxford Clinical Policy

Facet Joint Injections for Spinal Pain

Policy Number: PAIN 024.2 T2 Effective Date: November 1, 2021

Instructions for Use

Table of Contents

Page

Coverage Rationale...........................................................................1

Documentation Requirements.........................................................2

Definitions...........................................................................................3

Prior Authorization Requirements...................................................3

Applicable Codes..............................................................................4

Description of Services...................................................................12

Clinical Evidence.............................................................................12

U.S. Food and Drug Administration..............................................16

References .......................................................................................16

Policy History/Revision Information..............................................17

Instructions for Use.........................................................................17

Related Policies ? Ablative Treatment for Spinal Pain ? Epidural Steroid Injections for Spinal Pain ? Occipital Neuralgia and Headache Treatment

Coverage Rationale

Note: This policy addresses medial branchblock and intraarticular Facet Joint Injections of the cervical, thoracic and lumbar spines.

The following are proven and medically necessary: ? An initial diagnostic facet joint injection/medial branch block to determinefacet joint origin when all of the following criteria

are met: o Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation); and o Clinicallysignificant improvement has not occurred (thepain remains at a 3 or more on a 1-10 pain scale) after a

minimum of four weeks of conservative care(including but not limited to pharmacotherapy, exercise, or physical therapy); and o Clinical findings and imaging studiessuggest no other cause of the pain (e.g., spinal stenosis with neurogenic claudication, disc herniation withradicular pain, infection, tumor, fracture, pain related to prior surgery); and o The spinal motion segment is not fused; and o A radiofrequency joint denervation/ablation procedureis being considered. ? A second facet joint injection/medial branchblock performed to confirm thevalidity of the clinical responseto the initial facet joint injection, when all of the following criteria are met: o Administered at the same level and side as the initial block o The initial diagnostic facet join injection produced a positive responseas demonstrated when all the following criteria are met: For at least the expected minimum duration of the effect of the local anesthetic and, Functional improvement that is specific to the individualwith demonstrable improvement in the physical functions

previously limited by the facetogenic pain; and A radiofrequency joint denervation/ablation procedureis being considered.

Facet joint injections/medial branch blocks are unproven and not medically necessary due to insufficient evidence of efficacy:

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

Page 1 of 18 Effective 11/01/2021

? If radiofrequency ablation procedure not considered as treatment option at therequested level(s). ? For treating spinal pain, after diagnostic injections have been completed ? After two facet injections/medialbranch blocks at the same level and same side (this is considered therapeutic rather than

diagnostic). ? Therapeutic Facet Joint Injections and/or facet nerve block (i.e., medialbranch block) for treating chronic spinal pain ? For a second facet joint injection/medial branch block if the initial injection did not confirm the joint as the source of pain. ? In the presence of untreated Radiculopathyat the samelevelas the intended diagnostic injection (with the exception of

Radiculopathy caused by a facet joint synovial cyst) ? If injection of volume of local anesthetics exceeds 0.5ml for medial branch blocks ? When performed under ultrasound guidance.

Documentation Requirements

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage but do not guaranteecoverage of the servicerequested.

Required Clinical Information

Facet Joint Injections for Spinal Pain

Initial Injection Medical notes documenting the following, when applicable: ? Diagnosis ? History of the medical condition(s)requiring treatment, including presence of untreated radiculopathy ? Documentationof signs and symptoms; include onset, duration, and frequency ? Physical exam, including findings on facet loading maneuvers ? Relevant medical and surgicalhistory

o History of previous spinal procedures/interventions, including but not limited to previous facet injection and previous surgery(ies)

? Treatments tried, failed, or contraindicated; include the dates and reason for discontinuation including but not limited to: o Pharmacotherapy o Exercise o Physical Therapy

? Quantification of change in pain level on a 1-10 pain scale before and after conservative treatment, including type and duration of conservative treatment

? Reports of all recent imaging studies and applicable diagnostics ? Physician treatment plan, including:

o Location of proposed injection (side and level) o Injected anesthetic volume plan o Plan for use of ultrasound guidance o Plan for radiofrequency ablation

Second Injection (when applicable) ? Relevant medical and surgicalhistory

o History of previous spinal procedures/interventions, including but not limited to previous facet injection and previous surgery(ies)

? Response to initial facet injection, including: o Duration of the effect o Functional improvement in the physicalfunctions previouslylimited by the facetogenic pain

? Physician treatment plan, including: o Location of proposed injection (side and level) o Injected anesthetic volume plan o Plan for use of ultrasound guidance o Plan for radiofrequency ablation

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

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Required Clinical Information Facet Joint Injections for Spinal Pain In addition to the above, additional documentation requirements may apply for CPT codes 64490 and 64493. Refer to the Utilization Review Guideline titled Outpatient Surgical Procedures ? Site of Servicein conjunction with the guidelines in this document.

Definitions

Acute Low Back Pain: Low back pain present for up to six weeks. The early acute phase is defined as less thantwo weeks and the late acute phaseis defined as two to six weeks, secondary to the potential for delayed-recovery or risk phases for the development of chronic low back pain. Low back pain can occur on a recurring basis. If there has been complete recovery between episodes, it is considered acuterecurrent. (Goertzet al., 2012)

Conservative Therapy: Consists of an appropriate combination of medication (for example, NSAIDs, analgesics, etc.) in addition to physical therapy, spinal manipulation therapy, cognitive behavioral therapy (CBT) or other interventions based on the individual's specific presentation, physical findings and imaging results. (AHRQ, 2013; Qassem, 2017; Summers, 2013)

Facet Joint Injections (FJIs): The injection of a local anesthetic and/or corticosteroid into the facet joint capsule. The injection/block applies directlyto the facet joint(s) blocked and not to the number of nerves blocked that innervate thefacet joint(s). Even though facet joint injectionscan be used to diagnose facet joint pain, a medial branch block is generally considered more appropriate. A diagnostic facet joint injection/medial branchblock is considered positive when there is at least 50% relief of pain for at least the expected minimum durationof the effect of the local anesthetic used.

Facet Joint Syndrome: A condition that leads to chronic spinal pain due to unclear etiology. The classic findings of facet joint syndrome are pain in the cervical or thoracic spine or low back radiating to the buttock and posterior thigh, pain due to hyperextension, pain on palpationof joint, and absenceof both radiculopathybelow the knee and neurologic deficits.

Facet Nerve Block: The injection of a local anesthetic and/or corticosteroid along the nerves supplying the facet joints. A diagnostic medial branch block is considered positive whenthere is at least 50% relief of pain for at least the expected minimum duration of the effect of the local anesthetic used.

Medial Branch Block: See Facet Nerve Block above.

Non-Radicular Back Pain: Pain which does not radiatealong a dermatome (sensory distribution of a single root). Appropriate imaging does not reveal signs of spinal nerveroot compression and thereis no evidence of spinal nerveroot compression seen on clinicalexam. (Lenahan, 2018)

Radicular Back Pain: Pain which radiates from the spine into the extremity along the courseof the spinal nerve root. The pain should follow the pattern of a dermatomeassociated with the irritated nerveroot identified. (Lenahan, 2018)

Radiculopathy: Radiculopathy is characterized by pain which radiates from the spine to extend outward to cause symptoms away from the source of the spinal nerveroot irritation. (Lenahan, 2018)

Subacute Low Back Pain: Low back pain with duration of greater than six weeks after injury but no longer than 12 weeks after onset of symptoms. (Goertzet al., 2012)

Prior AuthorizationRequirements

CPT Codes 0213T, 0214T, 0215T, 0216T, 0217T, and 0218T

Prior authorization is required in all sites of service.

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

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Notes: ? Participating providers in the office setting: Prior authorization is required for services performed in the officeof a

participating provider. ? Non-participating/out-of-network providers in the office setting: Prior authorization is not required but is encouraged for

out-of-network services. If prior authorizationis not obtained, Oxford will review for out-of-network benefits and medical necessity after the serviceis rendered.

CPT Codes 64490, 64491, 64492, 64493, 64494, and 64495

No referral or prior authorization is required when provided in the office setting; prior authorization is required in all other sites of service.

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and maynot be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered healthservice. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guaranteeclaim payment. Other Policies may apply.

CPT Code 0213T 0214T

0215T

0216T 0217T

0218T

64490 64491

64492

64493 64494

Description Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in additionto code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in additionto code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), cervicalor thoracic; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), cervicalor thoracic; second level (List separately in additionto code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), cervicalor thoracic; third and any additional level(s)(List separately in additionto code for primary procedure)

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), lumbar or sacral; single level

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), lumbar or sacral; second level (List separately in additionto code for primary procedure)

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

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CPT Code 64495

Description

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance(fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separatelyin addition to code for primary procedure)

CPT? is a registered trademark of the American Medical Association

Diagnosis Code G89.18 G89.28 G97.82 M41.20 M41.22 M41.23 M41.24 M41.25 M41.26 M41.27 M43.00 M43.01 M43.02 M43.03 M43.04 M43.05 M43.06 M43.07 M43.08 M43.09 M43.10 M43.11 M43.12 M43.13 M43.14 M43.15 M43.16 M43.17 M43.18 M43.19 M46.90 M46.91 M46.92 M46.93 M46.94 M46.95 M46.96

Description Other acute postprocedural pain Other chronic postprocedural pain Other postprocedural complications and disorders of nervous system Other idiopathic scoliosis, site unspecified Other idiopathic scoliosis, cervical region Other idiopathic scoliosis, cervicothoracic region Other idiopathic scoliosis, thoracic region Other idiopathic scoliosis, thoracolumbar region Other idiopathic scoliosis, lumbar region Other idiopathic scoliosis, lumbosacralregion Spondylolysis, site unspecified Spondylolysis, occipito-atlanto-axial region Spondylolysis, cervical region Spondylolysis, cervicothoracic region Spondylolysis, thoracic region Spondylolysis, thoracolumbar region Spondylolysis, lumbar region Spondylolysis, lumbosacral region Spondylolysis, sacral and sacrococcygeal region Spondylolysis, multiple sites in spine Spondylolisthesis, site unspecified Spondylolisthesis, occipito-atlanto-axial region Spondylolisthesis, cervical region Spondylolisthesis, cervicothoracic region Spondylolisthesis, thoracic region Spondylolisthesis, thoracolumbar region Spondylolisthesis, lumbar region Spondylolisthesis, lumbosacral region Spondylolisthesis, sacral and sacrococcygealregion Spondylolisthesis, multiplesites in spine Unspecified inflammatoryspondylopathy, site unspecified Unspecified inflammatoryspondylopathy, occipito-atlanto-axial region Unspecified inflammatoryspondylopathy, cervicalregion Unspecified inflammatoryspondylopathy, cervicothoracic region Unspecified inflammatoryspondylopathy, thoracic region Unspecified inflammatoryspondylopathy, thoracolumbar region Unspecified inflammatoryspondylopathy, lumbar region

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

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Diagnosis Code M46.97 M46.98 M46.99 M47.011 M47.012 M47.013 M47.014 M47.015 M47.016 M47.019 M47.021 M47.022 M47.029 M47.11 M47.12 M47.13 M47.14 M47.15 M47.16 M47.20 M47.21 M47.22 M47.23 M47.24 M47.25 M47.26 M47.27 M47.28 M47.811 M47.812 M47.813 M47.814 M47.815 M47.816 M47.817 M47.818 M47.819 M47.891 M47.892 M47.893 M47.894 M47.895

Description Unspecified inflammatoryspondylopathy, lumbosacral region Unspecified inflammatoryspondylopathy, sacraland sacrococcygeal region Unspecified inflammatoryspondylopathy, multiple sites in spine Anterior spinal artery compression syndromes, occipito-atlanto-axial region Anterior spinal artery compression syndromes, cervical region Anterior spinal artery compression syndromes, cervicothoracic region Anterior spinal artery compression syndromes, thoracic region Anterior spinal artery compression syndromes, thoracolumbar region Anterior spinal artery compression syndromes, lumbar region Anterior spinal artery compression syndromes, site unspecified Vertebral arterycompressionsyndromes, occipito-atlanto-axialregion Vertebral arterycompressionsyndromes, cervical region Vertebral arterycompressionsyndromes, site unspecified Other spondylosis with myelopathy, occipito-atlanto-axialregion Other spondylosis with myelopathy, cervical region Other spondylosis with myelopathy, cervicothoracic region Other spondylosis with myelopathy, thoracic region Other spondylosis with myelopathy, thoracolumbar region Other spondylosis with myelopathy, lumbar region Other spondylosis with radiculopathy, site unspecified Other spondylosis with radiculopathy, occipito-atlanto-axialregion Other spondylosis with radiculopathy, cervical region Other spondylosis with radiculopathy, cervicothoracic region Other spondylosis with radiculopathy, thoracic region Other spondylosis with radiculopathy, thoracolumbar region Other spondylosis with radiculopathy, lumbar region Other spondylosis with radiculopathy, lumbosacral region Other spondylosis with radiculopathy, sacral and sacrococcygeal region Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region Spondylosis without myelopathy or radiculopathy, cervical region Spondylosis without myelopathy or radiculopathy, cervicothoracic region Spondylosis without myelopathy or radiculopathy, thoracic region Spondylosis without myelopathy or radiculopathy, thoracolumbar region Spondylosis without myelopathy or radiculopathy, lumbar region Spondylosis without myelopathy or radiculopathy, lumbosacral region Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region Spondylosis without myelopathy or radiculopathy, site unspecified Other spondylosis, occipito-atlanto-axialregion Other spondylosis, cervical region Other spondylosis, cervicothoracic region Other spondylosis, thoracic region Other spondylosis, thoracolumbar region

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

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Diagnosis Code M47.896 M47.897 M47.898 M47.899 M47.9 M48.50XA M48.51XA M48.52XA M48.53XA M48.54XA M48.55XA M48.56XA M48.57XA M48.58XA

M51.14 M51.15 M51.16 M51.17 M51.26 M51.27 M80.08XA M80.0AXA M80.88XA M80.8AXA M84.48XA M84.58XA M84.68XA M96.1 S12.000A S12.001A S12.01XA S12.02XA S12.030A S12.031A S12.040A S12.041A S12.090A S12.091A S12.100A S12.101A S12.110A

Description Other spondylosis, lumbar region Other spondylosis, lumbosacral region Other spondylosis, sacral and sacrococcygeal region Other spondylosis, site unspecified Spondylosis, unspecified Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture Collapsed vertebra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, cervicothoracic region, initialencounter for fracture Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture Collapsed vertebra, not elsewhere classified, lumbosacral region, initialencounter for fracture Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture Intervertebral disc disorders with radiculopathy, thoracic region Intervertebral disc disorders with radiculopathy, thoracolumbar region Intervertebral disc disorders with radiculopathy, lumbar region Intervertebral disc disorders with radiculopathy, lumbosacral region Other intervertebral disc displacement, lumbar region Other intervertebral disc displacement, lumbosacral region Age-related osteoporosis withcurrent pathological fracture, vertebra(e), initial encounter for fracture Age-related osteoporosis withcurrent pathological fracture, other site, initial encounter for fracture Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture Other osteoporosis with current pathological fracture, other site, initial encounter for fracture Pathological fracture, other site, initial encounter for fracture Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture Pathological fracture in other disease, other site, initialencounter for fracture Postlaminectomy syndrome, not elsewhere classified Unspecified displaced fractureof first cervical vertebra, initial encounter for closed fracture Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for closed fracture Stable burst fractureof first cervical vertebra, initial encounter for closed fracture Unstable burst fracture of first cervical vertebra, initial encounter for closed fracture Displaced posterior arch fractureof first cervical vertebra, initial encounter for closed fracture Nondisplaced posterior arch fractureof first cervical vertebra, initial encounter for closed fracture Displaced lateralmass fracture of first cervical vertebra, initial encounter for closed fracture Nondisplaced lateral massfracture of first cervical vertebra, initial encounter for closed fracture Other displaced fracture of first cervical vertebra, initial encounter for closed fracture Other nondisplaced fractureof first cervical vertebra, initial encounter for closed fracture Unspecified displaced fractureof second cervical vertebra, initialencounter for closed fracture Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture Anterior displaced Type II dens fracture, initial encounter for closed fracture

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

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Diagnosis Code S12.111A S12.112A S12.120A S12.121A S12.130A

S12.131A

S12.14XA S12.150A

S12.151A

S12.190A S12.191A S12.200A S12.201A S12.230A

S12.231A

S12.24XA S12.250A

S12.251A

S12.290A S12.291A S12.300A S12.301A S12.330A

S12.331A

S12.34XA S12.350A

S12.351A

S12.390A S12.391A S12.400A S12.401A S12.430A

Description Posterior displaced Type II dens fracture, initial encounter for closed fracture Nondisplaced Type II dens fracture, initial encounter for closed fracture Other displaced dens fracture, initial encounter for closed fracture Other nondisplaced dens fracture, initial encounter for closed fracture Unspecified traumatic displaced spondylolisthesis of second cervical vertebra, initialencounter for closed fracture Unspecified traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture Type III traumatic spondylolisthesis of second cervical vertebra, initial encounter for closed fracture Other traumatic displaced spondylolisthesis of second cervicalvertebra, initial encounter for closed fracture Other traumatic nondisplaced spondylolisthesis of second cervical vertebra, initial encounter for closed fracture Other displaced fracture of second cervical vertebra, initial encounter for closed fracture Other nondisplaced fractureof second cervical vertebra, initial encounter for closed fracture Unspecified displaced fractureof third cervical vertebra, initial encounter for closed fracture Unspecified nondisplaced fracture of third cervical vertebra, initial encounter for closed fracture Unspecified traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture Unspecified traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture Type III traumatic spondylolisthesis of third cervical vertebra, initial encounter for closed fracture Other traumatic displaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture Other traumatic nondisplaced spondylolisthesis of third cervical vertebra, initial encounter for closed fracture Other displaced fracture of third cervical vertebra, initial encounter for closed fracture Other nondisplaced fractureof third cervical vertebra, initial encounter for closed fracture Unspecified displaced fractureof fourth cervical vertebra, initial encounter for closed fracture Unspecified nondisplaced fracture of fourth cervicalvertebra, initial encounter for closed fracture Unspecified traumatic displaced spondylolisthesis of fourth cervical vertebra, initialencounter for closed fracture Unspecified traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture Type III traumatic spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture Other traumatic displaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture Other traumatic nondisplaced spondylolisthesis of fourth cervical vertebra, initial encounter for closed fracture Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture Other nondisplaced fractureof fourth cervical vertebra, initial encounter for closed fracture Unspecified displaced fractureof fifth cervical vertebra, initial encounter for closed fracture Unspecified nondisplaced fracture of fifth cervical vertebra, initialencounter for closed fracture Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture

Facet Joint Injections for Spinal Pain UnitedHealthcare Oxford Clinical Policy

?1996-2021, Oxford Health Plans, LLC

Page 8 of 18 Effective 11/01/2021

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