Does P07.20 require prior authorization?

No, P07.20 does not require prior authorization (high confidence). Code is covered without prior authorization.

`P07.20`, Extreme immaturity of newborn, unspecified weeks of gestation

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation of conventional/prior therapies attempted (high concentrations of oxygen, ventilatory support, surfactant, high-frequency ventilation, alkalosis induction, neuromuscular blockade, etc.) and rationale for iNO as rescue/adjunct therapy.
Device and dosing records showing administration via FDA-approved device (e.g., INOmax) and recorded dose and duration.
Monitoring records: methemoglobin levels and nitrogen dioxide (NO2) monitoring (trials used continuous spectrophotometric monitoring of methemoglobin), and renal function monitoring for adult patients given risk of renal impairment.
For use in CDH: documentation of adequate lung recruitment and clinical/echocardiographic response within 24 hours to continue therapy (Canadian guidance).

Aetna considers inhaled nitric oxide (INO) therapy medically necessary as a component of the treatment of hypoxic respiratory failure in neonates 34 weeks gestation or greater when both of the following criteria are met: Neonates do not have congenital diaphragmatic hernia; and When conventional therapies such as administration of high concentrations of oxygen, hyperventilation, high-frequency ventilation, the induction of alkalosis, neuromuscular blockade, and sedation have failed or are expect [...]
Aetna considers INO therapy medically necessary for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease.
Aetna considers the diagnostic use of INO medically necessary as a method of assessing pulmonary vaso-reactivity in persons with pulmonary hypertension.
Use as adjunct or rescue therapy in perioperative pulmonary hypertensive crisis during congenital heart surgery
Q33.1 Accessory lobe of lung
Q33.2 Sequestration of lung

AETNA-CPB-0318, Palivizumab (Synagis)

AETNA-CPB-0518, Nitric Oxide, Inhalational (INO)

AETNA-CPB-0579, T-Wave Alternans

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