Appendix 1

Medical Necessity Criteria for the San Francisco Mental Health Plan

Covered Services must meet criteria listed in each section below:

1. Diagnosis

   Must have one of the following DSM-IV diagnoses, which will be the focus of the intervention being provided:

   Included Diagnoses:

   1. Pervasive Developmental Disorders, except Autistic Disorder excluded.
   2. Attention Deficit and Disruptive Behavior Disorders
   3. Feeding & Eating Disorders of Infancy or Early Childhood
   4. Elimination Disorders
   5. Other Disorders of Infancy, Childhood, or Adolescence
   6. Schizophrenia & Other Psychotic Disorders
   7. Mood Disorders
   8. Anxiety Disorders
   9. Somatoform Disorders
   10. Factitious Disorders
   11. Dissociative Disorders
   12. Paraphilias
   13. Gender Identity Disorders in Children
   14. Eating Disorders
   15. Impulse-Control Disorders Not Elsewhere Classified
   16. Adjustment Disorders
   17. Personality Disorders, excluding Antisocial Personality Disorder
   18. Medication-Induced Movement Disorders

   Excluded Diagnoses:

   1. Mental Retardation
   2. Dementia
   3. Organic Brain Syndrome
   4. Learning Disorders
   5. Motor Skills Disorder
   6. Communication Disorders
   7. Autistic Disorder Other Pervasive Developmental Disorders are included.
   8. Tic Disorders
   9. Delirium, Dementia, and Amnestic and Other Cognitive Disorders
   10. Mental Disorders Due to a General Medical Condition
   11. Substance-Related Disorders
   12. Sexual & Gender Identity Disorders, except Paraphilias and Gender Identity Disorders in Children which are included
   13. Sleep Disorders
   14. Antisocial Personality Disorder
   15. Other Conditions That May Be a Focus of Clinical Attention, except Medication Induced Movement Disorders which are included.
2. Impairment Criteria

   Must meet one of the following conditions as a result of the mental disorder(s) identified in the diagnostic criteria above:

   1. A significant impairment in an important area of life functioning, or
   2. A probability of significant deterioration in an important area of life functioning, or
   3. Children also qualify if there is a probability the child will not progress developmentally as individually appropriate.
3. Intervention Related Criteria

   Must meet all conditions listed below:

   1. The focus of proposed intervention is to address the condition identified in impairment criteria "B" above, and
   2. It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning, and/or for children it is probable the child will progress developmentally as individually appropriate, and
   3. The condition would not be responsive to physical healthcare-based treatment.