Inhaled Nitric Oxide - MEDICAID - FLORIDA

This policy covers inhaled nitric oxide (iNO) as a pulmonary vasodilator for treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN) and related neonatal causes (e.g., meconium aspiration, pneumonia, sepsis, idiopathic PPHN), with selected pediatric uses such as postoperative pulmonary hypertension and acute vasoreactivity testing during right heart catheterization. Coverage is generally limited to neonates/infants (with some pediatric indications), requires use in conjunction with ventilatory support and prior failure or expected failure of conventional therapies, excludes congenital diaphragmatic hernia and chronic outpatient use, and is subject to plan-specific eligibility and medical director review.

"No explicit exclusions or non-covered situations are stated in this excerpt."

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