Inhaled Nitric Oxide - MEDICAID - OKLAHOMA

This policy covers inhaled nitric oxide (iNO) for pulmonary vasodilation—primarily to treat hypoxic respiratory failure from persistent pulmonary hypertension of the newborn (PPHN), for postoperative pulmonary hypertension in infants/children, and for acute vasoreactivity testing during right‑heart catheterization. Coverage is limited to term/near‑term neonates (≥34 weeks gestation, birth through 28 days) used adjunctively with ventilatory support after conventional therapies have failed, requires clinical/echocardiographic evidence of PPHN, is generally limited to 14 days or until oxygenation improves, and excludes specified populations/indications (e.g., congenital diaphragmatic hernia, preterm <34 weeks, adult ARDS, bronchopulmonary dysplasia, PVOD, and other non‑listed uses).

"Neonatal respiratory distress syndrome without PPHN ${ }^{8,15,22}"

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