P07.20 — Extreme immaturity of newborn, unspecified weeks of gestation
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of conventional/prior therapies attempted (high concentrations of oxygen, ventilatory support, surfactant, high-frequency ventilation, alkalosis induction, neuromuscular blockade, etc.) and rationale for iNO as rescue/adjunct therapy.
- Device and dosing records showing administration via FDA-approved device (e.g., INOmax) and recorded dose and duration.
- Monitoring records: methemoglobin levels and nitrogen dioxide (NO2) monitoring (trials used continuous spectrophotometric monitoring of methemoglobin), and renal function monitoring for adult patients given risk of renal impairment.
- For use in CDH: documentation of adequate lung recruitment and clinical/echocardiographic response within 24 hours to continue therapy (Canadian guidance).
Key Coverage Criteria
- Aetna considers inhaled nitric oxide (INO) therapy medically necessary as a component of the treatment of hypoxic respiratory failure in neonates 34 weeks gestation or greater when both of the following criteria are met: Neonates do not have congenital diaphragmatic hernia; and When conventional therapies such as administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, the induction of alkalosis, neuromuscular blockade, and sedation have failed or are expect [...]
- Aetna considers INO therapy medically necessary for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease.
- Aetna considers the diagnostic use of INO medically necessary as a method of assessing pulmonary vaso-reactivity in persons with pulmonary hypertension.
- Use as adjunct or rescue therapy in perioperative pulmonary hypertensive crisis during congenital heart surgery
- Q33.1 Accessory lobe of lung
- Q33.2 Sequestration of lung
3 Active Policies
AETNA-CPB-0318 — Palivizumab (Synagis)
AETNA-CPB-0518 — Nitric Oxide, Inhalational (INO)
AETNA-CPB-0579 — T-Wave Alternans
Related Codes
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