ModifiedCurativePolicy CHP-IP-2026-049

A049. Adrenal Crisis and Acute Adrenal Insufficiency

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Medical-necessity criteria for acute inpatient admission, level-of-care assignment, continued stay, and discharge readiness for Curative commercial PPO and EPO members with adrenal crisis or acute decompensated adrenal insufficiency across all ages.

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ModifiedCurativePolicy CHP-IP-2026-049

A049. Adrenal Crisis and Acute Adrenal Insufficiency

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Policy Summary

PayerCurative

PolicyA049. Adrenal Crisis and Acute Adrenal Insufficiency

Policy CodePolicy CHP-IP-2026-049

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least one clinical severity finding and one hospital-level service requirement to support acute inpatient admission.

SourceLink

POLICY UPDATE CHANGES

The policy uses immediate hydrocortisone 100 mg followed by 200 mg per 24 hours as the acute parenteral replacement regimen, replacing the prior 50 mg every 6 to 8 hours schedule.

The policy permits observation or outpatient management for selected impending crises and stable suspected chronic adrenal insufficiency when inpatient criteria are not met.

The policy adds monitored-bed criteria for severe hyponatremia because glucocorticoid replacement can cause rapid sodium correction.

100 mg IVInitial hydrocortisone dose

200 mg/24 hSubsequent hydrocortisone dose

12/24 hContinued-stay review

1–2 weeksEndocrinology follow-up

Admission, Level of Care, Continued Stay, and Discharge

Acute inpatient admission

Covered when ALL of the following are met.

Admission criteria

Clinical severity finding
- Severity findings
  - Adrenal crisis is present.Systolic blood pressure below 100 mmHg or 20 mmHg or more below baseline
  - Shock or hypotension is not responding to fluids in a member with suspected adrenal insufficiency.
  - Serum sodium is below 130 mmol/L, potassium is above 5.5 mmol/L, or glucose is below 70 mg/dL.
  - Altered mental status is present, or persistent vomiting prevents oral glucocorticoid intake after emergency treatment.
  - Acute kidney injury or severe dehydration is present.
  - A serious precipitant is present, such as sepsis, pneumonia, gastroenteritis with dehydration, surgery, trauma, or bilateral adrenal hemorrhage.
Hospital-level service
- Parenteral hydrocortisone is required.
  Hydrocortisone 100 mg followed by 200 mg per 24 hours; pediatric dosing is 50 to 100 mg/m² initially, followed by 50 to 100 mg/m²/day.
- Isotonic fluid resuscitation is required with glucose and electrolyte monitoring every 4 to 6 hours.
  For example, 1 liter in the first hour.
- Vasopressor support or invasive hemodynamic monitoring is required.
- Inpatient treatment of the precipitating illness is required.

Observation or outpatient instead of inpatient

Observation or outpatient management is appropriate when ANY criterion applies and no inpatient criterion is met.

Lower-acuity management

Impending crisis is present in a member with known adrenal insufficiency, without hypotension, hyponatremia below 130 mmol/L, or hypoglycemia; the member responds to parenteral hydrocortisone and fluids and can resume oral stress-dose glucocorticoid within 12 to 24 hours.Observation is generally up to 24 hours.
Suspected chronic adrenal insufficiency is being evaluated in a stable patient with outpatient morning cortisol and ACTH stimulation testing.

Intensive care unit

ICU placement is appropriate when ANY criterion is present.

ICU criteria

Hypotension persists after hydrocortisone and 2 liters of fluid, or vasopressors are required.
GCS is 12 or lower, or seizures or coma are present.
Severe electrolyte or cardiac abnormality
- Potassium is 6.5 mmol/L or higher or an arrhythmia is present.
- Sodium is below 120 mmol/L with neurologic symptoms.
Bilateral adrenal hemorrhage has ongoing bleeding, or septic shock is present.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY criterion is present and ICU criteria are not met.

Intermediate-care criteria

Hypotension has responded to hydrocortisone and fluids but requires blood-pressure checks every 1 to 2 hours for the first 12 to 24 hours.
Monitored electrolyte abnormality
- Potassium is 5.5 to below 6.5 mmol/L and cardiac monitoring is required.
- Sodium is 120 to below 125 mmol/L and sodium checks every 4 hours are required.

Medical-surgical unit

A medical-surgical bed is appropriate when ANY criterion applies and higher-level criteria are not met.

Medical-surgical criteria

The member is hemodynamically stable on parenteral hydrocortisone with improving electrolytes.
The member is tapering from stress-dose to oral maintenance glucocorticoid while the precipitant is treated or new-diagnosis education is provided.

Discharge readiness

Covered discharge readiness requires ALL of the following.

Discharge criteria

The member is hemodynamically stable on oral glucocorticoid for at least 24 hours.
Sodium is 130 mmol/L or higher and correcting at a safe rate, potassium is below 5.5 mmol/L, and glucose is stable.
Oral medications and diet are tolerated, and the precipitant has been treated.
A maintenance regimen is prescribed.Hydrocortisone 15 to 25 mg/day in divided doses, or equivalent; plus fludrocortisone 0.05 to 0.1 mg/day for primary adrenal insufficiency.
Sick-day rule education is completed, an emergency injectable hydrocortisone kit is prescribed, and a steroid emergency card or medical alert identification is provided.

Continued stay

Continued stay is medically necessary when ANY criterion is documented.

Ongoing inpatient need

Persistent hypotension or vasopressor need remains.
Parenteral hydrocortisone remains necessary because oral intake is not tolerated.
Uncorrected metabolic abnormality
- Sodium remains below 130 mmol/L.
- Potassium remains above 5.5 mmol/L.
- Hypoglycemia is not yet corrected.

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review.

Non-qualifying scenarios

Admission is solely for diagnostic ACTH stimulation testing in a hemodynamically stable patient.
Testing can be performed as an outpatient.
Continued stay occurs after the member is stable on oral glucocorticoid solely to complete education that can be delivered in an outpatient endocrinology visit.
This applies when the member can demonstrate injection technique and has an emergency kit.
The member is stable and remains hospitalized while awaiting outpatient adrenal CT or pituitary MRI.
Route to physician review and discharge planning; already authorized days are not retroactively denied.

Outpatient evaluation of suspected chronic adrenal insufficiency is outside the scope of this policy. The policy addresses acute inpatient admission, level-of-care assignment, continued stay, and discharge readiness for adrenal crisis or acute decompensated adrenal insufficiency.

An admission solely for diagnostic ACTH stimulation testing in a hemodynamically stable patient does not meet medical-necessity criteria because the testing can be performed outpatient. Such requests are referred for physician review rather than denied by an automated system or non-physician reviewer.

A continued stay after the member is stable on oral glucocorticoid does not meet criteria when the only remaining need is education that can be provided during an outpatient endocrinology visit. This applies when the member can demonstrate injection technique and has an emergency kit.

Days spent awaiting outpatient adrenal CT or pituitary MRI in a stable patient do not meet medical-necessity criteria. Imaging should be completed as an outpatient, with the case routed for physician review and discharge planning; already authorized days are not retroactively denied.

Diagnosis, DRG, Revenue, and Clinical Thresholds

ICD-10-CM: adrenal insufficiency and crisisICD-10

E27.1	Adrenal insufficiency and crisis
E27.2	Adrenal insufficiency and crisis
E27.40	Adrenal insufficiency and crisis

ICD-10-CM: drug-induced, other, and postprocedural adrenal insufficiency; hypopituitarismICD-10

E27.3	Drug-induced, other, and postprocedural adrenal insufficiency; hypopituitarism
E27.49	Drug-induced, other, and postprocedural adrenal insufficiency; hypopituitarism
E89.6	Drug-induced, other, and postprocedural adrenal insufficiency; hypopituitarism
E23.0	Drug-induced, other, and postprocedural adrenal insufficiency; hypopituitarism

MS-DRG: endocrine disordersMS-DRG

643	Endocrine disorders
644	Endocrine disorders
645	Endocrine disorders

Revenue codesRevenue

0120
0200
0206
0250
0300
0636
0762

Adrenal crisis hypotension

Absolute hypotensionSystolic blood pressure below 100 mmHg

Relative hypotensionSystolic blood pressure 20 mmHg or more below baseline

Clinical contextAdrenal crisis or acute adrenal insufficiency with a qualifying hypotensive finding

Admission electrolyte and glucose severity

SodiumBelow 130 mmol/L

PotassiumAbove 5.5 mmol/L

Authorization, Documentation, and Review Requirements

Documentation Required

Admission Medical Necessity

Document that acute inpatient admission meets both required elements: at least one clinical severity finding in a member with known or suspected adrenal insufficiency and at least one hospital-level service.

Clinical severity findings may include systolic blood pressure below 100 mmHg or at least 20 mmHg below baseline; fluid-unresponsive shock or hypotension; sodium below 130 mmol/L, potassium above 5.5 mmol/L, glucose below 70 mg/dL; altered mental status; persistent vomiting preventing oral glucocorticoid intake; acute kidney injury; severe dehydration; or a serious precipitant.
Hospital-level services may include parenteral hydrocortisone, isotonic fluid resuscitation with glucose and electrolyte monitoring, vasopressor support or invasive hemodynamic monitoring, or inpatient treatment of the precipitating illness.

Documentation Required

Concurrent Continued-Stay Review

Document ongoing acute inpatient needs for continued stay. Review continued stay every 12 hours in the ICU and every 24 hours in other settings.

Persistent hypotension or vasopressor need.

Clinical Context

Adrenal crisis is a life-threatening state of acute glucocorticoid deficiency that may cause rapid clinical deterioration, including hypotension and other signs of circulatory instability. Common manifestations include hyponatremia, hyperkalemia in primary adrenal insufficiency, hypoglycemia, vomiting, abdominal pain, fever, and confusion. Clinical improvement after parenteral glucocorticoid supports the diagnosis.

Key Clinical Definitions

Adrenal crisis

Acute deteriorationAcute deterioration in a person with known or suspected adrenal insufficiency

Absolute hypotensionSystolic blood pressure below 100 mmHg

Relative hypotension and responseBlood pressure 20 mmHg or more below baseline, with improvement within 1 to 2 hours after parenteral glucocorticoid

Impending adrenal crisis

Underlying conditionKnown adrenal insufficiency

Acute triggerAcute illness, vomiting, or inability to take oral glucocorticoid

Blood pressure

Policy Summary

PayerCurative

PolicyA049. Adrenal Crisis and Acute Adrenal Insufficiency

Policy CodePolicy CHP-IP-2026-049

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least one clinical severity finding and one hospital-level service requirement to support acute inpatient admission.

SourceLink

On This Page

Endocrinology follow-up is arranged within 1 to 2 weeks, with a diagnostic evaluation plan for new cases.

The diagnostic plan may include ACTH, renin, and imaging as indicated.

The precipitant, such as sepsis, still requires inpatient treatment.

GlucoseBelow 70 mg/dL

ICU hemodynamic threshold

Persistent hypotensionHypotension persisting after hydrocortisone and 2 liters of fluid

Vasopressor supportRequirement for vasopressors

Care levelEither finding supports intensive care unit placement

ICU neurologic threshold

Glasgow Coma ScaleGCS 12 or lower

SeizuresSeizures are present

ComaComa is present

ICU electrolyte threshold

Potassium6.5 mmol/L or higher

ArrhythmiaArrhythmia is present

Sodium with neurologic symptomsSodium below 120 mmol/L with neurologic symptoms

Step-down electrolyte threshold

Potassium5.5 to below 6.5 mmol/L, requiring cardiac monitoring

Sodium120 to below 125 mmol/L, requiring sodium checks every 4 hours

Level-of-care conditionApplies when ICU criteria are not met

Discharge laboratory threshold

Sodium130 mmol/L or higher and correcting at a safe rate

PotassiumBelow 5.5 mmol/L

GlucoseStable

Discharge oral stability

Hemodynamic statusHemodynamically stable

MedicationReceiving oral glucocorticoid

DurationStable on oral glucocorticoid for at least 24 hours

Continued parenteral hydrocortisone because oral intake is not tolerated.

Sodium below 130 mmol/L, potassium above 5.5 mmol/L, or uncorrected hypoglycemia.

A precipitant, such as sepsis, still requiring inpatient treatment.

Documentation Required

Discharge Authorization

Authorize discharge only when the member is clinically stable and all discharge-readiness elements are documented.

Hemodynamically stable on oral glucocorticoid for at least 24 hours; sodium is at least 130 mmol/L and correcting safely; potassium is below 5.5 mmol/L; and glucose is stable.
Tolerating oral medications and diet, with the precipitant treated.
Maintenance regimen prescribed, including hydrocortisone 15–25 mg/day in divided doses or equivalent, and fludrocortisone 0.05–0.1 mg/day for primary adrenal insufficiency.
Sick-day education completed; emergency injectable hydrocortisone kit prescribed; steroid emergency card or medical-alert identification provided; and endocrinology follow-up arranged within 1–2 weeks.
For new cases, document a diagnostic evaluation plan, including ACTH, renin, and imaging as indicated.

Billing Rule

Concurrent Review for Continued Stays

Apply concurrent review to each continued-stay period. Days already authorized must not be retroactively denied, and expected length of stay is a planning benchmark rather than a limit on covered days.

Review each period based on the member’s documented status and ongoing acute needs.
Do not retroactively deny days that were previously authorized.

Unsupported block type: documentation

Documentation Required

Hemodynamic Response

Document the blood-pressure trend relative to baseline and the member’s response to hydrocortisone.

Include baseline and serial blood-pressure values.
Describe the hemodynamic response after hydrocortisone administration.

Documentation Required

Laboratory Evaluation

Document the laboratory evaluation relevant to adrenal crisis or acute adrenal insufficiency.

Sodium, potassium, glucose, and creatinine.
Random cortisol and ACTH drawn before hydrocortisone when doing so does not delay treatment.

Documentation Required

Precipitant Evaluation

Document evaluation for the illness precipitating the adrenal crisis or acute adrenal insufficiency.

Record the suspected or confirmed precipitant and the diagnostic evaluation performed.
Examples include sepsis, pneumonia, gastroenteritis with dehydration, surgery, trauma, or bilateral adrenal hemorrhage.

Documentation Required

Steroid Treatment Plan

Document the hydrocortisone treatment administered and the planned transition or taper.

Include parenteral hydrocortisone doses and timing.
Document the taper plan and transition to the maintenance glucocorticoid regimen.

Documentation Required

Discharge Education and Follow-Up

Before discharge, document education and follow-up needed for safe outpatient management.

Sick-day rules and emergency injection technique reviewed.
Emergency injectable hydrocortisone kit prescribed.
Steroid emergency card or medical-alert identification provided.
Endocrinology follow-up arranged within 1–2 weeks.

Billing Rule

Support the Requested Scope of Services

Documentation must support the full scope of services requested, including the quantity, units, and duration.

If the service meets criteria but the requested quantity, units, or duration exceed what the record supports, approve the supported portion and separately review only the unsupported increment.

Denial Risk

Diagnostic Testing Alone

A stable patient admitted solely for ACTH stimulation testing does not meet medical-necessity criteria under this policy.

ACTH stimulation testing can be performed in the outpatient setting when the patient is hemodynamically stable.
Requests in this circumstance are referred for physician review rather than denied by an automated system or non-physician reviewer.

Denial Risk

Education-Only Continued Stay

A continued stay solely to complete education that can be delivered in an outpatient endocrinology visit does not meet criteria when there is no ongoing acute need.

The member should be able to demonstrate injection technique and have an emergency kit.
Refer the request for physician review rather than issuing an automated or non-physician denial.

Denial Risk

Stable Patient Awaiting Outpatient Imaging

Days spent waiting for outpatient adrenal CT or pituitary MRI in a stable patient do not meet medical-necessity criteria.

Imaging should be completed as an outpatient when clinically appropriate.
Route the request to physician review and discharge planning; do not retroactively deny days already authorized.

Billing Rule

Physician Review Requirement

Requests that do not meet the stated criteria, including requests for diagnostic testing alone, education-only continued stay, or outpatient imaging delays, must be referred for physician review.

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination.
The absence of a criterion addressing a service is not, by itself, a basis for an adverse determination; a physician must apply generally accepted standards of medical practice.

Billing Rule

Physician Review Required for Adverse Determinations

Only a licensed physician of the same or similar specialty may issue an adverse determination.

The requesting provider must first be offered a peer-to-peer discussion.
The reviewing physician must meet applicable licensure, specialty, and medical-director requirements of the plan’s situs state.

Billing Rule

Unsupported Quantity or Duration

When a service meets criteria but the requested quantity, units, or duration exceed what the documentation supports, approve the supported portion and separately review only the unsupported excess.

Do not deny the supported portion solely because the request includes an unsupported increment.
Apply concurrent review to each continued-stay period, without retroactively denying days already authorized.

Stress dosing (sick-day rules)

Febrile illnessDouble or triple the oral glucocorticoid dose

VomitingUse injectable hydrocortisone when vomiting prevents oral dosing

Unable to take oral dosesUse injectable hydrocortisone when oral glucocorticoid cannot be taken