Will the claim be denied? This question cannot be answered without more information. The treatment of pulmonary hypertension depends on the underlying cause. Depending on the underlying cause, treatments such as medications, lifestyle changes, oxygen therapy, and/or surgery may be recommended. If the cause is secondary to one of the conditions listed in the context (connective tissue disease, thromboembolic disease of the pulmonary arteries, HIV infection, cirrhosis, etc.), then the claim may be denied if the pulmonary hypertension has not progressed despite maximal medical and/or surgical treatment of the identified condition. In addition, the mean pulmonary artery pressure must be greater than 25 mm Hg at rest or greater than 30 mm Hg with exertion, and the beneficiary must have significant symptoms from the pulmonary hypertension.
When is the following treatment medically necessary for the condition specified? Treatment of pulmonary hypertension can include lifestyle changes such as reducing salt intake and quitting smoking, medications such as calcium channel blockers, endothelin receptor antagonists, and prostacyclin analogues, and in certain cases, lung or lobar retransplantation. Lung or lobar retransplantation is considered medically necessary for individuals with graft failure of an initial lung or lobar transplant due to either technical reasons or hyperacute rejection, and for individuals with chronic rejection or recurrent disease who meet general selection criteria.
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