Inhaled Nitric Oxide - MEDICAID - VIRGINIA

This policy covers inhaled nitric oxide (iNO) administration as a pulmonary vasodilator for treatment of persistent pulmonary hypertension of the newborn (PPHN) and associated hypoxic respiratory failure, with additional mention of postoperative pulmonary hypertension management in infants/children and use for acute vasoreactivity testing during right heart catheterization. Coverage is generally limited to term or near‑term neonates (≥34 weeks to 28 days) when used with ventilatory support after conventional therapy has failed or is expected to fail, requires absence of congenital diaphragmatic hernia, is typically limited to 14 days of treatment, and is subject to plan‑level criteria and coding requirements.

"Clinical or echocardiographic evidence of PPHN must be present (as this is an indicated condition)."

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