CurrentUnitedHealthcarePolicy CS173.K

Inhaled Nitric Oxide Therapy – Community Plan Medical Policy

UnitedHealthcare Community Plan medical policy CS173.K defines clinical indications, exclusions, evidence summary, and applicable coding for inhaled nitric oxide (iNO) therapy in neonates and infants; includes recommendations for term/near-term infants, preterm infants, congenital diaphragmatic hernia (CDH), and postoperative pulmonary hypertension management in infants. This part (1 of 2) contains coverage rationale, clinical evidence, guidelines, FDA approvals, definitions, and one CPT reference.

Policy Summary

PayerUnitedHealthcare

PolicyInhaled Nitric Oxide Therapy – Community Plan Medical Policy

Policy CodePolicy CS173.K

Change TypeTemplate/Application updates (non-material)

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must document gestational age (>=34 weeks), diagnosis of hypoxic respiratory failure or echocardiographic evidence of PPHN, and absence of CDH to support iNO coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update (no material change noted).

>=34 weeksGestational age threshold for primary coverage

Preterm <34wNot medically necessary population

CDHExcluded condition

1CPT codes referenced