EXHIBIT D, COVERED BEHAVIORAL HEALTH DIAGNOSES

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1 EXHIBIT D, COVERED BEHAVIORAL HEALTH DIAGNOSES Part I- Mental Health Covered Diagnoses Schizophrenic s (the following fifth-digit sub-classification is for use with category 295) 0 unspecified 1 subchronic 2 chronic 3 subchronic with acute exacerbation 4 chronic with acute exacerbation 5 in remission Simple type Disorganized type Catatonic type Paranoid type Acute schizophrenic episode Latent schizophrenia Residual type Schizoaffective Other specified types of schizophrenia Unspecified schizophrenia 296 Episodic mood s (the following fifth-digit subclassification is for use with categories ) 0 unspecified 1 mild 2 moderate 3 severe, without mention of psychotic behavior 4 severe, specified as with psychotic behavior 5 in partial or unspecified remission 6 in full remission Bipolar I, single manic episode Manic, recurrent episode Major depressive, single episode Major depressive, recurrent episode Bipolar I, most recent episode (or current) manic Bipolar I, most recent episode (or current) depressed Bipolar I, most recent episode (or current) mixed Bipolar I, most recent episode (or current) unspecified Page 1 of 12

2 296.8 Other and unspecified bipolar s Bipolar, unspecified Atypical manic Atypical depressive Other Other and unspecified episodic mood Unspecified episodic mood Other specified episodic mood 297 Delusional s Paranoid state, simple Delusional Paraphrenia Shared psychotic Other specified paranoid states Unspecified paranoid state 298 Other nonorganic psychoses Depressive type psychosis Excitative type psychosis Reactive confusion Acute paranoid reaction Psychogenic paranoid psychosis Other and unspecified reactive psychosis Unspecified psychosis Anxiety, dissociative and somatoform s Anxiety states Anxiety state, unspecified Panic without agoraphobia Generalized anxiety Other Dissociative, conversion and factitious s Hysteria, unspecified Conversion Dissociative amnesia Dissociative fugue Dissociative identity Dissociative or reaction, unspecified Factitious illness with predominantly psychological signs and symptoms Other and unspecified factitious illness Page 2 of 12

3 300.2 Phobic s Phobia, unspecified Agoraphobia with panic attacks Agoraphobia without mention of panic attacks Social phobia Other isolated or specific phobias Obsessive-compulsive s Dysthymic Neurasthenia Depersonalization Hypochondriasis Somatoform s Somatization Undifferentiated somatoform Other Somatoform Unspecified nonpsychotic 301 Personality s Paranoid personality Affective personality Affective personality, unspecified Chronic hypomanic personality Chronic depressive personality Cyclothymic Schizoid personality Schizoid personality, unspecified Introverted personality Schizotypal personality Explosive personality Obsessive-compulsive personality Histrionic personality Histrionic personality, unspecified Chronic factitious illness with physical symptoms Other histrionic personality Dependent personality Antisocial personality Other personality s Narcissistic personality Avoidant personality Borderline personality Passive-aggressive personality Page 3 of 12

4 Other Unspecified personality Special symptoms or syndromes, not elsewhere classified Anorexia nervosa Tics Tic, unspecified Transient tic Chronic motor or vocal tic Tourette s Stereotypic movement Specific s of sleep of nonorganic origin Nonorganic sleep, unspecified Transient of initiating or maintaining sleep Persistent of initiating or maintaining sleep Transient of initiating or maintaining wakefulness Persistent of initiating or maintaining wakefulness Circadian rhythm sleep of nonorganic origin Sleep arousal Other s of sleep stages or arousal from sleep Repetitive intrusions of sleep Other Other and unspecified s of eating Eating, unspecified Bulimia nervosa Pica Rumination Psychogenic vomiting Other Enuresis Encopresis Pain s related to psychological factors Psychogenic pain, site unspecified Tension headache Other Other and unspecified special symptoms or syndromes, not elsewhere classified 308 Acute reaction to stress Predominant disturbance of emotions Page 4 of 12

5 308.1 Predominant disturbance of consciousness Predominant psychomotor disturbance Other acute reactions to stress Mixed s as reactions to stress Unspecified acute reaction to stress 309 Adjustment reaction Adjustment with depressed mood Prolonged depressive reaction With predominant disturbance of other emotions Separation anxiety Emancipation of adolescence and early adult life Specific academic or work inhibition Adjustment with anxiety Adjustment with mixed anxiety and depressed mood Other Adjustment with disturbance of conduct Adjustment with mixed disturbance of emotions and conduct Other specified adjustment reactions Post-traumatic stress Adjustment reaction with physical symptoms Adjustment reaction with withdrawal Other Unspecified adjustment reaction Depressive, not elsewhere classified 312 Disturbance of conduct, not elsewhere classified (the following fifth-digit sub-classification is for use with categories ) 0 unspecified 1 mild 2 moderate 3 severe Undersocialized conduct, aggressive type Undersocialized conduct, unaggressive type Socialized conduct Disorders of impulse control, not elsewhere classified Impulse control, unspecified Pathological gambling Kleptomania Pyromania Intermittent explosive Page 5 of 12

6 Isolated explosive Other Mixed disturbance of conduct and emotions Other specified disturbance of conduct, not elsewhere classified Conduct, childhood onset type Conduct, adolescent onset type Other conduct Unspecified disturbance of conduct 313 Disturbance of emotions specific to childhood and adolescence Overanxious Misery and unhappiness Sensitivity, shyness, and social withdrawal Shyness of childhood Introverted of childhood Selective mutism Relationship problems Other or mixed emotional disturbances of childhood or adolescence Oppositional defiant Identity Academic underachievement Other Unspecified emotional disturbance of childhood or adolescence 314 Hyperkinetic syndrome of childhood Attention deficit Without mention of hyperactivity With hyperactivity Hyperkinesis with developmental delay Hyperkinetic conduct Other specified manifestations of hyperkinetic syndrome Unspecified hyperkinetic syndrome Part 2- Substance Use Disorder Covered Diagnoses ICD-9 DSM-IV Alcohol Use Disorders 291 Alcohol-induced mental -- No equivalent DSM-IV code s 303 Alcohol dependence syndrome -- No equivalent DSM-IV code Page 6 of 12

7 303.9 [0-3]* Other and unspecified alcohol dependence Alcohol dependence [0-3] Alcohol abuse Alcohol abuse 305 Nondependent abuse of drugs -- No equivalent DSM-IV code Alcohol-Induced Disorders [0-3] Acute alcohol intoxication Alcohol intoxication Alcohol withdrawal Alcohol withdrawal Alcohol withdrawal delirium Alcohol withdrawal delirium Alcohol intoxication delirium Alcohol intoxication delirium Alcohol induced persisting amnesic Alcohol induced psychotic Alcohol induced psychotic Other alcohol induced mood Other alcohol induced anxiety Other alcohol induced sexual Alcohol induced persisting amnesic Alcohol induced psychotic Alcohol induced psychotic Alcohol induced mood Alcohol induced anxiety Alcohol induced sexual Alcohol induced sleep s Alcohol induced sleep s Unspecified alcohol induced s Alcohol-related not otherwise specified (NOS) Amphetamine Use Disorders 304 Drug dependence -- No equivalent DSM-IV code [0-3] Amphetamine and other psychostimulant dependence Amphetamine dependence [0-3] Amphetamine or related acting sympathomimetic abuse Amphetamine abuse Amphetamine Induced Disorders 292 Drug-induced s -- No equivalent DSM-IV code Other specified drug induced Amphetamine intoxication Drug withdrawal Amphetamine withdrawal Drug induced delirium Amphetamine intoxication delirium Page 7 of 12

8 Drug induced psychotic Amphetamine induced psychotic Amphetamine induced psychotic Drug induced mood Amphetamine induced mood Drug induced anxiety Amphetamine induced anxiety Drug induced sexual Amphetamine induced sexual Drug induced sleep Amphetamine induced sleep Amphetamine related s not otherwise specified Cannabis Use Disorders [0-3] Cannabis dependence Cannabis dependence [0-3] Cannabis abuse Cannabis abuse Cannabis Induced Disorders Other specified drug induced Cannabis intoxication s Drug-intoxication delirium Cannabis intoxication delirium Drug induced psychotic Cannabis induced psychotic Cannabis induced psychotic Drug induced anxiety Cannabis induced anxiety Cannabis related s not otherwise specified (NOS) Cocaine Use Disorders [0-3] Cocaine dependence Cocaine dependence [0-3] Cocaine abuse Cocaine abuse Cocaine Induced Disorders Page 8 of 12

9 Other specified drug induced Cocaine intoxication Drug withdrawal Cocaine withdrawal Drug intoxication delirium Cocaine intoxication delirium Drug induced psychotic Cocaine induced psychotic Cocaine induced psychotic Drug induced mood Cocaine induced mood Drug induced anxiety Cocaine induced anxiety Drug induced sexual Cocaine induced sexual Drug induced sleep Cocaine induced sleep Cocaine related s not otherwise specified (NOS) Hallucinogen Use Disorders [0-3] Hallucinogen dependence Hallucinogen dependence [0-3] Hallucinogen abuse Hallucinogen abuse Hallucinogen Induced Disorders Other specified drug induced s Hallucinogen intoxication Other specified drug induced s Hallucinogen persisting perception (flashbacks) Drug induced delirium Hallucinogen intoxication delirium Drug induced psychotic Hallucinogen induced psychotic with delusions Hallucinogen induced psychotic Drug induced mood Hallucinogen induced mood Page 9 of 12

10 Drug induced anxiety Hallucinogen induced anxiety Hallucinogen related s not otherwise specified (NOS) Inhalant Use Disorders [0-3] Other specified drug dependence Inhalant dependence [0-3] Other, mixed, or unspecified drug abuse Inhalant abuse Inhalant Induced Disorders Other specified drug induced Inhalant intoxication s Drug induced delirium Inhalant intoxication delirium Drug induced psychotic Inhalant induced psychotic Inhalant induced psychotic Drug induced mood Inhalant induced mood Drug induced anxiety Inhalant induced anxiety Inhalant related s not otherwise specified Opioid Use Disorders [0-3] Opioid type dependence Opioid dependence [0-3] Opioid abuse Opioid abuse Opioid Induced Disorders Other specified drug induced Opioid intoxication s Drug withdrawal Opioid withdrawal Drug induced delirium Opioid intoxication delirium Drug induced psychotic Opioid induced psychotic Opioid induced psychotic Drug induced mood Opioid induced mood Drug induced sexual Opioid induced sexual Page 10 of 12

11 Drug induced sleep Opioid induced sleep Opioid related s not otherwise specified [0-3] Other specified drug dependence Phencyclidine Use Disorders Phencyclidine dependence [0-3] Other, mixed, or unspecified drug use Phencyclidine abuse Phencyclidine Induced Disorders Other specified drug induced Phencyclidine intoxication s Drug intoxication delirium Phencyclidine intoxication delirium Drug induced psychotic Disorder with hallucinations Phencyclidine induced psychotic Phencyclidine induced psychotic Disorder with hallucinations Drug induced mood Phencyclidine induced mood Drug induced anxiety Phencyclidine induced anxiety Phencyclidine related s not otherwise specified (NOS) [0-3] Sedative-,hypnotic-,or anxiolytic dependence Sedative-,Hypnotic-,or Anxiolytic Use Disorders Sedative-,hypnotic-,or anxiolytic dependence [0-3] Sedative-,hypnotic-,or anxiolytic abuse Sedative-,hypnotic-,or anxiolytic abuse Sedative-,Hypnotic-,or Anxiolytic-Induced Disorders Other specified drug induced s Sedative-,hypnotic-,or anxiolytic intoxication Drug withdrawal Sedative-,hypnotic-,or anxiolytic withdrawal Drug induced delirium Sedative-,hypnotic-,or anxiolytic intoxication delirium Drug induced persisting amnestic Sedative-,hypnotic-,or anxiolytic induced persisting amnestic Page 11 of 12

12 Drug induced psychotic Sedative-,hypnotic-,or anxiolytic induced psychotic with delusions Sedative-,hypnotic-,or anxiolytic induced psychotic with hallucinations Drug induced mood Sedative-,hypnotic-,or anxiolytic induced mood Drug induced anxiety Sedative-,hypnotic-,or anxiolytic induced anxiety Drug induced sexual Sedative-,hypnotic-,or anxiolytic induced sexual Drug induced sleep Sedative-,hypnotic-,or anxiolytic induced sleep [0-3] Combinations of opioid type drug with any other Sedative-,hypnotic-,or anxiolyticrelated not otherwise specified * Polysubstance dependence [0-3] Combinations of drug dependence excluding opioid type drug Polysubstance dependence Tobacco Use Disorder Tobacco use Nicotine Dependence --No equivalent DSM IV code *Fifth digit sub-classification Subcategories: [0 unspecified; 1 continuous; 2 episodic; 3 in remission] Page 12 of 12

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