Diagnosis: Schizophrenia.
Treatment: Behavioral Health Inpatient Services.
The health plan denied Behavioral Health Inpatient Services. The health plan's determination is overturned in part. Six additional days of Behavioral Health Inpatient Services are medically necessary.

The patient is a male with diagnoses of chronic schizophrenia (SCZ), Cannabis Use D/O (CUD), and Ecstasy Use Disorder (EUD). He has required multiple psychiatric admissions. He has been non-adherent to his medication. The admission under review was initiated via emergency services due to the patient's violence and aggression toward his family (father and sister).

Six additional days are medically necessary for several reasons. This patient's SCZ is severe, chronic, and functionally impairing. His form of SCZ is of a very severe type, marked by prominent negative symptoms, and less responsive to medications. Additionally, his use of two substances made his treatment more complex. The patient was not able to tolerate the daily interview of the mental status but walked out of the room. He would not engage in attempts at group therapy. He was still disheveled. He had minimal spontaneous speech. He showed thought blocking and poverty of thoughts. He was illogical and appeared to be internally preoccupied. He reported no suicidal or homicidal ideation. He was not behaviorally aggressive. He denied hallucinations or delusions. He had no side effects from his medications. While he was very functionally impaired, he appeared to have reached his baseline state of functioning. His mood was good.
While he was still substantially impaired by his negative symptoms on day 5, he appears to have returned to his baseline state. There was no evidence predictive of violence. He had no suicidal ideation. He has no positive psychotic features. Therefore, he could be discharged on day 6 with good medical judgment, in accord with current standards of best care, and in accord with the medical literature. While his actual discharge appeared to be delayed beyond day 6 due to his family declining to take him back home, this was not a medical reason for continued BHIS.