CG-MED-69 Inhaled Nitric Oxide

This policy addresses inhaled nitric oxide (iNO). It is medically necessary for: term/near‑term neonates (≥34 weeks gestation) with hypoxic respiratory failure unresponsive to conventional therapy and without congenital diaphragmatic hernia; acute pulmonary vasoreactivity testing in pulmonary hypertension; and select neonatal/infant postoperative congenital heart disease care—short‑term prophylaxis in high‑risk patients to prevent pulmonary hypertensive crises and bridge therapy for severe, confirmed postoperative pulmonary hypertension causing clinical instability—when left ventricular function is preserved. iNO is not medically necessary for other uses, including hypoxic respiratory failure in premature neonates <34 weeks, neonatal pulmonary hypertension when criteria are not met, acute respiratory distress syndrome in adults, and broader unselected perioperative use.

"Therapeutic use of iNO is consideredmedically necessarywhen either criterion AorB is met:"