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PROTOCOL HISTORY/REVISION INFORMATION
Date
07/26/2012
01/26/2012
04/28/2011
01/28/2011
06/24/2010
06/26/2009
Action/Description
Corporate Medical Affairs Committee
The foregoing Health Plan of Nevada/Sierra Health & Life Health Operations protocol has been
adopted from an existing UnitedHealthcare coverage determination guideline that was researched,
developed and approved by the UnitedHealthcare Coverage Determination Committee.
Occipital Neuralgia & Headache Page 24 of 24