Inhaled Nitric Oxide - MEDICAID - LOUISIANA

This policy covers inhaled nitric oxide (iNO) for management of hypoxic respiratory failure due to persistent pulmonary hypertension of the newborn (PPHN), postoperative pulmonary hypertension in infants/children with congenital heart disease, and for acute vasoreactivity testing during pulmonary arterial hypertension evaluation. Coverage is limited to Humana Healthy Horizon Louisiana members, generally for term/near‑term neonates (≥34 weeks, birth–28 days) without congenital diaphragmatic hernia, requires failure or expected failure of conventional therapies, is typically limited to 14 days of treatment, and excludes non‑listed indications such as adult ARDS or PVOD testing.

"Treatment of hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn (PPHN)."

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