All PlansCoverageMedium impact
Inhaled Nitric Oxide
Blue Cross & Blue Shield of Mississippi·MS · Critical Care, Pediatrics, Pulmonology +1 more·Medical Policy
We identified it
Jun 20, 2026
Summary
This policy establishes coverage criteria for inhaled nitric oxide (INO), specifying it is medically necessary only for hypoxic respiratory failure in neonates over 34 weeks gestation, while all other uses including premature infants, adults, and surgical applications remain investigational. The policy provides specific clinical criteria including oxygenation index requirements for coverage determination.
Action Required
Immediately: Billing team must ensure claims for inhaled nitric oxide are only submitted for neonates over 34 weeks gestation with hypoxic respiratory failure and documented pulmonary hypertension. Verify oxygenation index of at least 25 on two measurements 15 minutes apart is documented. Flag any claims for premature infants, adults, children, or surgical uses as investigational and likely to be denied. Update prior authorization requests to include required clinical documentation.