Clinical UM Guideline
Subject: Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists
Guideline #: CG-ADMIN-01 Publish Date: 07/06/2022
Status: Reviewed Last Review Date: 05/12/2022
Description

The Company reviews services provided, or proposed to be provided, to its members to determine benefits coverage based on whether the services are medically necessary or not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice, taking into account credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors, as they relate to the member's clinical circumstances.

This document provides guidance to be followed and a list of resources available to Company Medical Reviewers when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes noted in the table below in connection with a provider who is on pre-payment review. These services and corresponding codes may be modified when additional inappropriate use of services is identified; services and codes may be added to the table accordingly.

After Company Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system. Utilization Management departments will follow their standard procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.

NOTE: PLEASE SEE THE DEFINITIONS OF "MEDICALLY NECESSARY" OR "MEDICAL NECESSITY" AND "INVESTIGATIONAL" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

 

71045

Radiologic examination, chest; single view

 

71046

Radiologic examination, chest, 2 views

 

71047

Radiologic examination, chest, 3 views

 

72020

Radiologic examination, spine, single view, specify level

 

72040

Radiologic examination, spine, cervical; 2 or 3 views

 

72050

Radiologic examination, spine, cervical; 4 or 5 views

 

72052

Radiologic examination, spine, cervical; 6 or more views

 

72070

Radiologic examination, spine; thoracic, 2 views

 

72074

Radiologic examination, spine; thoracic, minimum of 4 views

 

72082

Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views

 

72110

Radiologic examination, spine, lumbosacral; minimum of 4 views

 

72114

Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views

 

72170

Radiologic examination, pelvis; 1 or 2 views

 

73030

Radiologic examination, shoulder; complete, minimum of 2 views

 

73060

Radiologic examination; humerus, minimum of 2 views

 

73070

Radiologic examination, elbow; 2 views

 

73080

Radiologic examination, elbow; complete, minimum of 3 views

 

73090

Radiologic examination; forearm, 2 views

 

73110

Radiologic examination, wrist; complete, minimum of 3 views

 

73130

Radiologic examination, hand; minimum of 3 views

 

73502

Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views

 

73503

Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views

 

73521

Radiologic examination, hips, bilateral, with pelvis when performed; 2 views

 

73522

Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views

 

73523

Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views

 

73560

Radiologic examination, knee; 1 or 2 views

 

73564

Radiologic examination, knee; complete, 4 or more views

 

73590

Radiologic examination, tibia and fibula, 2 views

 

73600

Radiologic examination, ankle; 2 views

 

73610

Radiologic examination, ankle; complete, minimum of 3 views

 

73620

Radiologic examination, foot; 2 views

 

73630

Radiologic examination, foot; complete, minimum of 3 views

 

73660

Radiologic examination; toe(s), minimum of 2 views

 

74021

Radiologic examination, abdomen; 3 or more views

 

76536

Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), reald time with image documentation

 

76700

Ultrasound, abdominal, real time with image documentation; complete

 

76705

Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

 

76770

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

 

76775

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

 

76881

Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures), real-time with image documentation

 

76882

Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscles[s],nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation

 

93886

Transcranial Doppler study of the intracranial arteries; complete study

 

93888

Transcranial Doppler study of the intracranial arteries; limited study

 

93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

 

93892

Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

 

93893

Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

 

93975

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

 

93976

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study

 

96365

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

 

96366

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

 

96367

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

 

96368

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)

 

96369

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)

 

96370

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

 

96371

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)

96372

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96373

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial

96374

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

96375

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

96376

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure

96377

Application of on-body injector (includes cannula insertion) for timed subcutaneous injection

96379

Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion

ICD-10 Diagnosis

 

 

All diagnoses

**Note: In determining if there is a relevant Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is reported, the detailed description of service will be the determining factor.

Discussion/General Information

As noted above, this document provides guidance to be followed when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a claim related to the above services and codes in connection with a provider who is on pre-payment review. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources that may be relevant to the decision at hand, but not necessarily use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.

Definitions

Physician Specialty Society: A United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality (AHRQ) – Clinical Information. Available at: http://www.ahrq.gov/. Accessed on February 23, 2022.
  2. American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2022. Available at: http://www.abms.org/member-boards/specialty-subspecialty-certificates/. Accessed on February 23, 2022.
  3. Centers for Disease Control and Prevention (CDC). Available at: http://www.cdc.gov. Accessed on February 2, 2021.
  4. Centers for Medicare & Medicaid Services (CMS). Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on February 23, 2022.
  5. National Library of Medicine – PUBMED. Available at: http://www.ncbi.nlm.nih.gov/sites/entrez. Accessed on February 23, 2022.
  6. U.S. Food and Drug Administration (FDA). Available at: http://www.fda.gov. Accessed on February 23, 2022.
  7. Physician specialty societies where publicly available:

General Certificate(s)

Specialty Society

(+) Indicates Guidelines Publicly Available
(-) Indicates Guidelines Not Publicly Available

Subspecialty Certificate(s)

Allergy and Immunology

American Academy of Asthma, Allergy and Immunology (AAAAI) (+)
http://www.aaaai.org

American College of Allergy, Asthma and Immunology (ACAAI) (+)
https://acaai.org/

None

Anesthesiology

American Society of Anesthesiologists®
(ASA) (+)
For additional information visit the ASA website: https://www.asahq.org/

 

  1. Critical Care Medicine
  2. Hospice and Palliative Medicine
  3. Pain Medicine
  4. Pediatric Anesthesiology
  5. Sleep Medicine

Colon and Rectal Surgery

American Society of Colon and Rectal Surgeons (ASCRS) (+)
http://www.fascrs.org

None

Dermatology

American Academy of Dermatology (AAD) (-)
http://www.aad.org

  1. Dermatopathology
  2. Pediatric Dermatology

Emergency Medicine

American College of Emergency Physicians® (ACEP) (+)
https://www.acep.org/

  1. Anesthesiology Critical Care Medicine
  2. Emergency Medical Services
  3. Hospice and Palliative Medicine
  4. Internal Medicine- Critical Care Medicine
  5. Medical Toxicology
  6. Pain Medicine
  7. Pediatric Emergency Medicine
  8. Sports Medicine
  9. Undersea and Hyperbaric Medicine

Family Medicine

American Academy of Family Practice (AAFP) (-)
http://www.aafp.org

  1. Adolescent Medicine
  2. Geriatric Medicine
  3. Hospice and Palliative Medicine
  4. Pain Medicine
  5. Sleep Medicine
  6. Sports Medicine

Internal Medicine

 

 

American College of PhysiciansSM (ACP) (+)
http://www.acponline.org

  1. Adolescent Medicine
  2. Adult Congenital Heart Disease
  3. Advanced Heart Failure and Transplant Cardiology
  4. Cardiovascular Disease
  5. Clinical Cardiac Electrophysiology
  6. Critical Care Medicine
  7. Endocrinology, Diabetes and Metabolism
  8. Gastroenterology
  9. Geriatric Medicine
  10. Hematology
  11. Hospice and Palliative Medicine
  12. Infectious Disease
  13. Interventional Cardiology
  14. Medical Oncology
  15. Nephrology
  16. Pulmonary Disease
  17. Rheumatology
  18. Sleep Medicine
  19. Sports Medicine
  20. Transplant Hepatology

Medical Genetics

  1. Clinical Biochemical Genetics
  2. Clinical Cytogenetics and Genomics
  3. Clinical Genetics and Genomics (MD)
  4. Clinical Molecular Genetics and Genomics
  5. Laboratory Genetics and Genomics

American College of Medical Genetics (ACMG) (+)
http://www.acmg.net

  1. Medical Biochemical Genetics
  2. Molecular Genetic Pathology

Neurological Surgery

American Association of Neurological Surgeons (AANS) (+)
For additional information visit the AANS website: https://www.aans.org/

None

Nuclear Medicine

American College of Nuclear Medicine (ACNM) (-)
http://www.acnmonline.org

None

Obstetrics and Gynecology

American Congress of Obstetricians and Gynecologists (ACOG) (-)
http://www.acog.org

  1. Critical Care Medicine
  2. Female Pelvic Medicine and Reconstructive Surgery
  3. Gynecologic Oncology
  4. Hospice and Palliative Medicine
  5. Maternal and Fetal Medicine
  6. Reproductive Endocrinology/ Infertility

Ophthalmology

American Academy of Ophthalmology (AAO) (+)
For additional information visit the AAO website: https://www.aao.org/

None

Orthopaedic Surgery

American Academy of Orthopaedic Surgeons (AAOS) (+)
http://www.aaos.org

  1. Orthopaedic Sports Medicine
  2. Surgery of the Hand

Otolaryngology

American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+)
http://www.entnet.org

  1. Neurotology
  2. Pediatric Otolaryngology
  3. Plastic Surgery Within the Head and Neck
  4. Sleep Medicine

Pathology

  1. Pathology-Anatomic/ Pathology-Clinical
  2. Pathology-Anatomic
  3. Pathology-Clinical

College of American Pathologists
(CAP) (+)
http://www.cap.org

  1. Blood Banking/Transfusion Medicine
  2. Clinical Informatics
  3. Cytopathology
  4. Dermatopathology
  5. Neuropathology
  6. Pathology – Chemical
  7. Pathology – Forensic
  8. Pathology – Hematology
  9. Pathology – Medical Microbiology
  10. Pathology – Molecular Genetic
  11. Pathology - Pediatric

American Society for Clinical Pathology (ASCP) (-)
http://www.ascp.org

Pediatrics

American Academy of Pediatrics (AAP) (+)
http://www.aap.org

  1. Adolescent Medicine
  2. Child Abuse Pediatrics
  3. Developmental-Behavioral Pediatrics
  4. Hospice and Palliative Medicine
  5. Medical Toxicology
  6. Neonatal-Perinatal Medicine
  7. Neurodevelopmental Disabilities
  8. Pediatric Cardiology
  9. Pediatric Critical Care Medicine
  10. Pediatric Emergency Medicine
  11. Pediatric Endocrinology
  12. Pediatric Gastroenterology
  13. Pediatric Hematology-Oncology
  14. Pediatric Hospital Medicine
  15. Pediatric Infectious Diseases
  16. Pediatric Nephrology
  17. Pediatric Pulmonology
  18. Pediatric Rheumatology
  19. Pediatric Transplant Hepatology
  20. Sleep Medicine
  21. Sports Medicine

Physical Medicine and Rehabilitation

American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+)
http://www.aapmr.org

  1. Brain Injury Medicine
  2. Hospice and Palliative Medicine
  3. Neuromuscular Medicine
  4. Pain Medicine
  5. Pediatric Rehabilitation Medicine
  6. Spinal Cord Injury Medicine
  7. Sports Medicine

Plastic Surgery

American Society of Plastic Surgeons® (ASPS) (+)
http://www.plasticsurgery.org

  1. Plastic Surgery Within the Head and Neck
  2. Surgery of the Hand

Preventive Medicine

  1. Aerospace Medicine
  2. Occupational Medicine
  3. Public Health and General Preventive Medicine

American College of Preventive Medicine (AAPM) (-)
http://www.acpm.org

  1. Addiction Medicine
  2. Clinical Informatics
  3. Medical Toxicology
  4. Undersea and Hyperbaric Medicine

American College of Occupational and Environmental Medicine (ACOEM) (-)
http://www.acoem.org

Psychiatry and Neurology

  1. Psychiatry
  2. Neurology
  3. Neurology with Special Qualification in Child Neurology

American Psychiatric Association (APA) (+)
http://www.psych.org

  1. Addiction Psychiatry
  2. Brain Injury Medicine
  3. Child and Adolescent Psychiatry
  4. Clinical Neurophysiology
  5. Consultation-Liaison Psychiatry
  6. Epilepsy
  7. Forensic Psychiatry
  8. Geriatric Psychiatry
  9. Hospice and Palliative Medicine
  10. Neurocritical Care*
  11. Neurodevelopmental Disabilities
  12. Neuromuscular Medicine
  13. Pain Medicine
  14. Sleep Medicine
  15. Vascular Neurology

American Academy of Child & Adolescent Psychiatry (AACAP) (+)
http://www.aacap.org

American Academy of Neurology® (AAN) (+)
http://www.aan.com

Child Neurology Society (CNS) (-)
http://www.childneurologysociety.org

Radiology

  1. Diagnostic Medical Physics
  2. Diagnostic Radiology
  3. Interventional Radiology and Diagnostic Radiology
  4. Nuclear Medical Physics
  5. Radiation Oncology
  6. Therapeutic Medical Physics

American College of Radiology (ACR®) (+)
http://www.acr.org
NOTE: Do not confuse with American College of Rheumatology

  1. Hospice and Palliative Medicine
  2. Neuroradiology
  3. Nuclear Radiology
  4. Pediatric Radiology
  5. Vascular and Interventional Radiology

American Society for Therapeutic Radiation and Oncology ASTRO (+)
For additional information visit the ASTRO website:
https://www.astro.org/

Surgery and Vascular Surgery

American College of Surgeons (ACS) (+)
http://www.facs.org
NOTE: Do not confuse with American Cancer Society.

  1. Complex General Surgical Oncology
  2. Hospice and Palliative Medicine
  3. Pediatric Surgery
  4. Surgery of the Hand
  5. Surgical Critical Care

Thoracic and Cardiac Surgery

Society of Thoracic Surgeons (STS) (+)
http://www.sts.org/

Congenital Cardiac Surgery

Urology

American Urological Association (AUA) (+)

For additional information visit the AUA website:
https://www.auanet.org/education/clinical-practice-guidelines.cfm

  1. Female Pelvic Medicine and Reconstructive Surgery
  2. Pediatric Urology

Subspecialty Societies

Subspecialty Certificate

Specialty Society

(+) Indicates Guidelines Publicly Available
(-) Indicates Guidelines Not Publicly Available

Cardiology

American College of Cardiology (ACC) (+)
http://www.acc.org

Society for Cardiovascular Angiography and Interventions (SCAI) (+)
http://www.scai.org/Default.aspx

Clinical Cardiac Electrophysiology

Heart Rhythm SocietySM (HRS) (+) (collaborative with ACC)
http://www.hrsonline.org/

Critical Care Medicine

Society of Critical Care Medicine (SCCM) (+)

For additional information visit the SCCM website:
http://www.sccm.org/Home

Endocrinology, Diabetes and Metabolism

American Association of Clinical Endocrinologists AACE (+)
http://www.aace.com

Endocrine Society (-)
http://www.endo-society.org

Gastroenterology

American College of Gastroenterology (ACG) (+)
https://gi.org/

American Gastroenterological Association (AGA) (+)
http://www.gastro.org

Society of American Gastrointestinal and Endoscopic Surgeons SAGES (+)
https://www.sages.org/

Geriatric Medicine

American Geriatrics Society (AGS) (+)
http://www.americangeriatrics.org

Geriatric Psychiatry

American Association for Geriatric Psychiatry (AAGP) (+)
http://www.aagponline.org/

Gynecologic Oncology

Society of Gynecologic Oncology (SGO) (+)
http://www.sgo.org

Hematology

American Society of Hematology (ASH) (+)
http://www.hematology.org

Hospice and Palliative Medicine

American Academy of Hospice and Palliative Medicine

(AAHPM) (-)
http://www.aahpm.org

Infectious Disease

Infectious Disease Society of America (IDSA) (+)
http://www.idsociety.org

Medical Toxicology

American College of Medical Toxicology (-)
http://www.acmt.net

Nephrology

American Society of Nephrology (ASN) (-)
http://www.asn-online.org

Neuromuscular

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) (+)
http://www.aanem.org/Home.aspx

Neuroradiology

American Society of Neuroradiology (ASNR) (-)
http://www.asnr.org

Oncology

American Society of Clinical Oncology (ASCO®) (+)
http://www.asco.org

Pain Medicine

American Chronic Pain Association (ACPA) (+)

https://www.theacpa.org/

American Academy of Pain Medicine (AAPM) (+)

https://painmed.org/

Pulmonary Disease

American College of Chest Physicians® (ACCP) (+)
http://www.chestnet.org

Reproductive Endocrinology/Infertility

American Society for Reproductive Medicine (ASRM) (+)
http://www.asrm.org

Rheumatology

American College of Rheumatology (ACR) (+) 

For additional information visit the ACR website:
http://www.rheumatology.org/

NOTE: Do not confuse with American College of Radiology

Sleep Medicine

American Academy of Sleep Medicine (AASM) (+)
http://www.aasmnet.org

Sports Medicine

American Orthopaedic Society for Sports Medicine (AOSSM) (-)
http://www.sportsmed.org

Surgery of the Hand

American Society for Surgery of the Hand (ASSH) (-)
https://www.assh.org/ 

Transplant Hepatology

American Association for the Study of Liver Diseases (AASLD) (+)
http://www.aasld.org

American Society of Transplantation (AST) (+)
https://www.myast.org/

Undersea and Hyperbaric Medicine

Undersea and Hyperbaric Medical Society (UHMS) (-)
https://www.uhms.org/

Vascular and Interventional Radiology

Society of Interventional Radiology (SIR) (+)
http://www.sirweb.org

Vascular Surgery

Society for Vascular Surgery (SVS) (+)
www.vascularweb.org/

Index

Radiograph
Ultrasound
X-Ray

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

05/12/2022

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References.

Reviewed

05/13/2021

MPTAC review.

Reviewed

05/14/2020

MPTAC review. Updated References.

Revised

06/06/2019

MPTAC review. Revised Coding and References section to create separate sections. Updated References. Updated Coding section with CPT codes 96365-96379.

Revised

09/13/2018

MPTAC review. Added new entry and references for CPT codes 93886-93893. Added reference for AIUM practice guideline for the performance of ultrasound of the female pelvis to 93975 and 93976. Updated References.

Reviewed

02/27/2018

MPTAC review.

 

01/01/2018

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT changes; added codes 71045-71047 and 74021, removed codes 71010, 71020, 71021, and 74020 deleted 12/31/2017.

Revised

02/02/2017

MPTAC review. Updated document with references for added CPT codes 76881, 76882, 93975 and 93976.

New

08/04/2016

MPTAC review. Initial document development.


Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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