Therapeutic Utilization of Inhaled Nitric Oxide

This policy covers therapeutic use of inhaled nitric oxide (iNO) to improve oxygenation in term and near‑term neonates and infants (generally ≥34 weeks gestation) with hypoxic respiratory failure/PPHN, perioperative pulmonary vasodilation or pulmonary hypertensive crisis after cardiac surgery, and select cases such as severe COVID‑19 ARDS, per the specified indications. Coverage requires strict criteria—failure of conventional therapies, often an oxygen index (OI) >25 for initiation, gestational age ≥34 weeks (requests for <34 weeks reviewed case‑by‑case), exclusion of unrepaired CDH except as a bridge to repair, many other indications deemed not medically necessary, and extended use beyond 72 hours requires medical director review.

"Term and near-term neonates with hypoxic respiratory failure for improvement of oxygenation (iNO has been shown to improve oxygenation and reduce need for ECMO in this population)."