Diagnosis: Adrenal Insufficiency
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is overturned

Patient is a female who was diagnosed with Post-Partum Sheehan's Syndrome. She has other past medical history (PMH) of hyperlipidemia (HLD), diabetes mellitus (DM) and Depression. The patient presented to the emergency department (ED) with complaint of (C/O) Weakness, Near Syncope. Patient C/O some nausea, vomiting and diaphoresis symptoms.

Patient had hypotension noted in ED (emergency department) with blood pressure (BP) in 90/60 mm Hg (millimeters of mercury) range. She was started on intravenous (IV) hydration. She was in no acute distress (NAD). Lungs were clear Cardiovascular (CVS) s1 (heartbeat) S2 (heartbeat) normal. The patient was alert and oriented (A x O X 3). Neuro exam was Non focal.

Labs revealed white blood cell count (WBC) of 10.8K (thousand) Hb (hemoglobin) 15.9 Electrolytes were within normal limits (WNL) BUN (blood urea nitrogen) / Creatinine 21/0.8.

The patient's Cortisol Level was 1.2 and TSH (thyroid stimulating hormone) was 0.9.

Chest x-ray was WNL and Pulmonary computed tomography (CT) Angiogram was negative for pulmonary embolism (PE).

Patient was diagnosed with Acute on Chronic Adrenal Insufficiency. Other possibilities included Hypovolemia secondary to dehydration, Cardiac/Neurological or a Vasovagal episode.

Patient was admitted to Telemetry. Myocardial infarction (MI) was ruled out (R/o) by serial Troponins and EKG (electrocardiogram). Patient was continued on IV fluids. Prednisone dose was initially increased from 5 mg (milligrams) daily to 15 mg /day.

The patient was transferred out of Telemetry but continued to remain hypotensive with Systolic BP in 90's with readings as low as 91/60.

The patient was evaluated by Endocrinology. They recommended to increase prednisone dose to 30 mg in the AM (morning) and 15 mg in PM (evening). Patient was also placed on Thyroid replacement with Levothyroxine.

This patient most likely had Acute on Chronic Adrenal Insufficiency and needed adjustment of her Steroid dosing. Adrenal insufficiency is a life-threatening condition and needs to be treated promptly and aggressively. The patient continued to have episodes of hypotension even after that. Therefore, it was appropriate to keep the patient in hospital to monitor for signs and symptoms of acute adrenal insufficiency.

The patient slowly stabilized with increased dose of steroids and thyroid replacement as per Endocrine recommendations and was discharged (dced) after stability was achieved.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.