Port 5667 NSCA is used primarily by the Nagios Distributed monitoring service. NSCA used by remote monitoring servers(perhaps running or not running Nagios) to submit passive check information.
Ports 12489 and 5666 need not be open to the Nagios Server, but rather from Nagios as a Client. You will likely wish to add a great deal to this list, I'll take a stab at what you might what to use as a base.
ICMP 8 ( echo request)/ ICMP 0 (echo reply)
80/443 25 22 993 995 110 143 220 21 23 53 69