Inhaled Nitric Oxide - MEDICAID - SOUTH CAROLINA

This policy covers inhaled nitric oxide (iNO) as a selective pulmonary vasodilator for treatment of persistent pulmonary hypertension of the newborn (PPHN) in term/near‑term infants (≥34 weeks) with hypoxic respiratory failure, and for select uses including postoperative pulmonary hypertension in infants/children with congenital heart disease and acute vasoreactivity testing (VRT) in adults with pulmonary arterial hypertension to identify calcium‑channel‑blocker responders. Coverage is limited to the listed indications, requires failure/contraindication/intolerance of conventional therapies for neonatal use, excludes infants with congenital diaphragmatic hernia, generally limits therapy to ≤14 days or until oxygenation resolves, and other uses are considered not medically necessary.

"Treatment of persistent pulmonary hypertension of the newborn (PPHN) to improve oxygenation and reduce the need for extracorporeal membrane oxygenation (ECMO)."