Inhaled Nitric Oxide (INO) - (0453)

Cigna covers inhaled nitric oxide (iNO) only for specific indications — hypoxic respiratory failure in term/near‑term infants (>34 weeks) without congenital diaphragmatic hernia after failure/contraindication to conventional therapy, postoperative pulmonary hypertension/post‑op pulmonary hypertensive crisis in congenital heart disease or pediatric heart/lung surgery, and acute vasoreactivity testing during right‑heart catheterization — and considers iNO not medically necessary for other uses (including ARDS, most preterm infants <34 weeks, adult heart/lung transplantation, routine prevention of BPD, and other listed indications). Coverage is limited to a maximum of 14 days when criteria are met and requires FDA‑guided dosing (typically 20 ppm, avoid >20 ppm), continuous monitoring (PaO2, methemoglobin, inspired NO2), documented failure/contraindication to conventional therapy, gestational age and absence of CDH for neonates, and appropriate documentation/billing or claims will be denied.