Diagnosis: Cancer - Pancreas Cancer
Treatment: Skilled Nursing Facility

The patient is a male admitted secondary to weakness and fatigue with recent diagnosis of cyst of pancreas, diabetes mellitus type 2, renal insufficiency, atrial fibrillation, anemia, edema, generalized weakness, hypertension, gastroesophageal reflux disease, hypotension, diarrhea and pressure ulcer of left ankle stage I. The patient was admitted for skilled services secondary to weakness and fatigue. The health plan denied the skilled services as not medically necessary.

The health plan's determination is upheld.

Based upon the records provided the patient has multiple medical problems including fatigue secondary to his underlying diagnosis. There was significant improvement with physical therapy over the course of therapy. Recently, the patient was able to ambulate sufficiently to maintain in an apartment. There was no notation in the record that the patient would need chronic long-term custodial care. It is reasonable to say that in 2 months of physical therapy the patient did have significant improvement however, there was a notation according to the appeal that the patient's home situation was not ideal in regards to continuing his outpatient care. There is a notation that the patient did not have a good family support system that was reasonably close to help him out. However, there was no specific medical necessity for ongoing inpatient skilled care. The patient's level of function is adequate for a home situation. Further treatment and therapy can be continued as an outpatient.