Autopap and Straight C-Pap

Gilda,

You might try an apap, but the C-flex won't give 4cm in exhalation pressure relief. If you have infrequent events but require a high pressure an apap may benefit you. Do you know what you AHI was during your sleep study? In your case, if you can tolerate the bipap it may be best for you. If you can't tolerate it an apap may be an alternative better than using nothing.

Wader,

My AHI was 12 per hour and 81% LSAT and 46 PLMD for a total of 58 arousals events per hour. Total sleep minutes were 180. I am being treated for the Period Limb Movement Disorder with medication, I don't know if it is helping but I do feel better in the mornings. I do no have any software for my bi-level since my insurance is rent to own. Once the machine is mine, then I plan to get some software. My DME also has the machine set to the simple menu so I can not see anything but ramp time and hours used.

Thanks for the reply,
Gilda

hi Gilda,

You wrote:

I called my DME today and asked about an autopap with c/flex, stated that I would like to try one. She said that it was like my bi-level in that it drops to a lower pressure for exhale. I told her that was not what I understood it to be, that it sensed what pressure was needed to open the air way and used ONLY the pressure that was needed at the time. I told her I thought the c/flex addition was the part that dropped the pressure for exhale. Was I correct?

Yes, you are absolutely correct, Gilda. Since the Respironics REMstar AUTO with C-flex is fairly new, the DME may not even know about it. Amazing that they don't keep themselves informed about state of the art in their own field, but...a lot of them don't. Some Respironics CPAP machines, on the other hand, have had C-Flex as a feature for a long time. Probably the DME is so used to hearing CPAP with C-flex, she zeroed in on the word "C-flex" and didn't even listen to what you said about "auto". Or perhaps she thought you misspoke.

There isn't necessarily a correlation between how many events you have (AHI) and what pressure is needed to keep your throat open. As Wader pointed out, if lower pressures are able to preventively keep your throat open and 18 is needed only occasionally (and possibly not at all!) you may get better relief by using an autopap with C-flex than you are currently getting with that straight 18 hitting you all night long, even though the bi-level machine can be set to give a precise drop in exhalation....and as Wader said, can be set to drop a lot more than the drop one gets from C-Flex. Given all the variables though, I think auto with C-flex is definitely worth a try. 18 is tough, and you just might not need that much.

I don't know if this was the case at your sleep study, nor do I know what position you normally sleep in at home, but here's another factor that could have stuck you with that high pressure of 18: Most sleep clinics want you to sleep on your back (supine) as much as possible. That position is where a person is most likely to have apneas and hypopneas - gravity making the tissues around the throat more likely to collapse the throat when you are flat on your back. The sleep clinic wants to see "worst case scenario". And when you are titrated to find the pressure needed, they again want you on your back if possible - to be able to treat "worst case scenario". I don't know if you spent much time on your back at the study.

However, at home, it may be that you seldom sleep on your back and sleep mostly on your side, perhaps turning from side to side...not staying on your back even if you turn over. In that case, it's very likely you really don't need "18" very often, or at all. The throat stays open better when we are on our side. Just something to consider when we think about how titrations are done at most sleep clinics. Some encourage you to do as much of the study as possible on your back, and some want you to sleep in your normal positions - if you can, while wired up.

One word about software for the bipap you have now. I looked back in some of your previous posts and couldn't find your mentioning the brand/model bi-level machine you are currently using. I don't know if all of the bi-levels give the same amount of data that you'd be interested in. Before spending money on software, do make sure the machine isn't designed to give only "compliance data"....that would mean only "hours of use" and wouldn't have the important data like how many apneas, how many hypopneas, etc.

The major "big three" brands of autopaps' software do, of course, give you detailed information. Good luck, Gilda!

Yes it is very sad but true. Most dme's shy away from auto cpap because they are reimbursed the same for an auto as for a regular cpap. Now I don't expect any sympathy to the dme's but that is the reason why they will not use them. Companies like Res Med have been fighting long and hard to get a specific auto cpap code established but Medicare is refusing. Basically unless Medicare gives it a code then no one else will either.

Here's the bad news...I don't see that changing anytime soon. If they give autos a code then the dme's will be giving them out left and right knowing the reimbursement is higher. (yes, now that there is money involved the dme is suddenly willing to provide equipment that will help a patient) I am a confessed DME-er...but that is how things work at most companies. Here is what is more likely to happen.

The manufacturers will start pushing bipap again. They will say that all their studies show increased compliance when using bipap. (bilevel) Which might be true in the case of compliance, especially in patients with higher pressures. Bipap is expensive to the provider but the reimbursement in general is pretty good. I don't when it comes to auto vs bipap...I guess it is six on one hand, half a dozen on the other. The manufacturers are usually the ones who set the pace in the market and that is mostly driven by insurance reimbursement unfortunately.

As far as using auto instead of bipap....Make sure you talk to your doc first!! Sometimes bipap is used for benefits other than treating OSA. Bipap can be used to improve oxygen saturation especially in patients with some co-existing pulmonary problems. Make sure your md only prescribed it to treat your OSA.

MelMel

Lst I knew about social security and Medicare, is doesn't one HAVE TO BE OVER 65 for medicare? I cannot speak for medicaid, as that's administered by thes states.

So the argument about "medicare reimbursement" falls short when for now a majority of users/insurance problems, are UNDER 65, and either have their own plan, covered under a group, or have no coverage at all.

All pap users can't be lumped together for one insurance DOGMA and excuse by DME"s for reimbursement.

I'd suggest that all potential cpap, bipap, apap (and any other pap's) check with their insurance individually, take names, times, codes, whatever insurance tells you re: your own coverage. Same ole' story, if you don't do this yourself, you're at the mercy of some DME/RT/dr. pushing for a cheap machine, Higher commisssions and forget-em attitude, we've experienced.

But getting off my thread train, melmel, your comments are well taken re: medicare, but proportionally I think more cpap users might not be medicare ready at least from the ages alluded to on this board?

Maybe a good survey in the works by the admin. what is average age, give or take or cpap starters, etc.?

Mel, it's good to know they're diligent and smart DME's out there.
Interested in what we have to say..etc.

My DME frankly and readily admitted she knew nothing about the 420E, or the new H20, we had to read the manual together. I'll give her an 'a' for honesty, and effort, but it was a time waster for. she actually told me that the PB sales rep had to ''show'' her my machine......how to program it, etc.

One can hope that some of the DME/dr/RT resistance to auto's will level out as the word gets out via the 'net...

MelMel wrote:Yes it is very sad but true. Most dme's shy away from auto cpap because they are reimbursed the same for an auto as for a regular cpap. Now I don't expect any sympathy to the dme's but that is the reason why they will not use them. Companies like Res Med have been fighting long and hard to get a specific auto cpap code established but Medicare is refusing. Basically unless Medicare gives it a code then no one else will either.

Here's the bad news...I don't see that changing anytime soon. If they give autos a code then the dme's will be giving them out left and right knowing the reimbursement is higher. (yes, now that there is money involved the dme is suddenly willing to provide equipment that will help a patient) I am a confessed DME-er...but that is how things work at most companies. Here is what is more likely to happen.

The manufacturers will start pushing bipap again. They will say that all their studies show increased compliance when using bipap. (bilevel) Which might be true in the case of compliance, especially in patients with higher pressures. Bipap is expensive to the provider but the reimbursement in general is pretty good. I don't when it comes to auto vs bipap...I guess it is six on one hand, half a dozen on the other. The manufacturers are usually the ones who set the pace in the market and that is mostly driven by insurance reimbursement unfortunately.

As far as using auto instead of bipap....Make sure you talk to your doc first!! Sometimes bipap is used for benefits other than treating OSA. Bipap can be used to improve oxygen saturation especially in patients with some co-existing pulmonary problems. Make sure your md only prescribed it to treat your OSA.

MelMel

Hi gailzee... I just wanted to clarify.

The reason that I referenced Medicare was because in a sense Medicare is who either accepts or denies the creation of the billing codes used by all insurance companies. They are called HCPCS codes. If Medicare or what is called the SADMERC does not approve the codes then they are not nationally recognized as a code. My point being that if there is not a specific code for an auto cpap then the dme must bill it under E1399 which is a generic miscellaneous code. I have seen with certain hmo's or third party payers that they will review claims on a case by case basis but for the most part the E1399 code is the kiss of death.

Hopefully that makes sense, but I just wanted you to know why I referenced Medicare. For the most part they make all the rules. It is the evil government this time.

Hope this helps,
MelMel

MelMel wrote:Hi gailzee... I just wanted to clarify.

The reason that I referenced Medicare was because in a sense Medicare is who either accepts or denies the creation of the billing codes used by all insurance companies. They are called HCPCS codes. If Medicare or what is called the SADMERC does not approve the codes then they are not nationally recognized as a code. My point being that if there is not a specific code for an auto cpap then the dme must bill it under E1399 which is a generic miscellaneous code. I have seen with certain hmo's or third party payers that they will review claims on a case by case basis but for the most part the E1399 code is the kiss of death.

Hopefully that makes sense, but I just wanted you to know why I referenced Medicare. For the most part they make all the rules. It is the evil government this time.

Hope this helps,
MelMel

Why bill it under misc? It is CPAP. Currently there is no distiction for APAP. I am pretty sure the same was done with BIPAP before there was a code. Insurance companies can and do cover APAP when using the generic cpap coding...

We can and do use the cpap code. But in reference to the evil dme's that is why they won't give out autos sometimes. Because they are more costly, but the reimbursement is the same. Unfortunately, until auto cpap has it's own code the dme's are not going to readily offer auto without the consumer having to pick up the difference.

Where I work we look at it like this... The owner of our company is a cpap patient himself so he is pretty supportive of anything that will improve patient care. We have a few hundred autos currently in the field. We use auto pretty frequently because if our patients are compliant and their cpap therapy successful then eventually it comes back to us in a positive way. The more compliant a patient is the more likely they will need a mask or filters in the future. I don't totally understand why most dme's haven't figured out that a little extra cost involved in helping a patient become compliant will pay for itself two times over based on positive PR and future sales. Sorry to talk about the business end of things but it is part of the big picture.

Anyway, long live auto cpap. I am anxious to see what new developments they come out with in the near future. Medtrade is a dme convention and the manufacturers usually release new products at the show. Medtrade West is in March and Medtrade East is October. I think ResMed is going to release some new products this year.

Mel Mel

Thanks all for the great info.

Yes Mel Mel, I will talk to my doctor before making any changes to any of my equipment. I want to live a long time and do not take my health and OSA lightly. I have already suffered from some of the effects of untreated OSA. I also had a oxygen saturation of 81%, so as you said, that maybe one of the reasons for the bipap. The DME stated the doctor ordered the bipap because the sleep tech said I was struggling to exhale against the 18 pressure. So the setting of 18/14 is what I have. I am simply trying to educate myself so I can explore all my options with my doctor on my next visit in mid March.

Thanks also to rested gal,

My sleep study was done with me getting 180 minutes of sleep total with, I think, most of the time on my side. The tech said I only went into "good" sleep for less than 30 minutes and since I only got around 3 hrs total sleep, I have some questions regarding the pressure of 18 and my needing it all the time. I will explore this with my doctor.

As for the bilevel, I am using the VPAP lll with heated humidifer and breeze nasal pillows. My users manual states that it gives AHI etc with needed software. Once this or whatever machine I end up with is mine, I will purchase the software for it.

Thanks all,
Gilda

Can you keep this board posted on new technologies you hear about at these conventions. I commend you for trying to explain the DME point of view, and listening to all our complaints.

But putting that aside, any new info would be greatly appreciated by all of us...It's all a learning curve for us....as well...!

Thanks!

MelMel wrote:We can and do use the cpap code. But in reference to the evil dme's that is why they won't give out autos sometimes. Because they are more costly, but the reimbursement is the same. Unfortunately, until auto cpap has it's own code the dme's are not going to readily offer auto without the consumer having to pick up the difference.

Where I work we look at it like this... The owner of our company is a cpap patient himself so he is pretty supportive of anything that will improve patient care. We have a few hundred autos currently in the field. We use auto pretty frequently because if our patients are compliant and their cpap therapy successful then eventually it comes back to us in a positive way. The more compliant a patient is the more likely they will need a mask or filters in the future. I don't totally understand why most dme's haven't figured out that a little extra cost involved in helping a patient become compliant will pay for itself two times over based on positive PR and future sales. Sorry to talk about the business end of things but it is part of the big picture.

Anyway, long live auto cpap. I am anxious to see what new developments they come out with in the near future. Medtrade is a dme convention and the manufacturers usually release new products at the show. Medtrade West is in March and Medtrade East is October. I think ResMed is going to release some new products this year.

Mel Mel