Correct Prescription based on these figures?

Hose_Head wrote:

Fitdiculous wrote: no, have not had the first titration yet, only the very 1st sleep study to help diagnose the OSA.

My first titration is scheduled for June 8th (3 weeks), but I have yet to get a machine yet (will 3 weeks be long enough to get "used" to one?)

from the info that the sleep clinic told me it almost seemed like they didn't LIKE giving out prescriptions for apap's... like there was extra work involved or something???

It sounds as though your sleep doctor follows a different process from the one that I went through. After I first met with my sleep doctor, after the first sleep study to diagnose OSA, I was immediately ushered into the office next door (same sleep clinic) to meet with the DME. (terrible conflict of interest in that). There, the DME gave me a loaner CPAP and sold me a piece of cr*p mask to use.

Have you been scheduled to meet with a DME? Is that meeting before your titration sleep study?

Everyone seems to react differently to cpap. Personally, I took to it like a duck to water. Lucky I guess. Others struggle with it and I'm led to believe that there's a very high failure rate.

Some sleep doctors don't like apaps, under any circumstances. Other's are willing to prescribe, but are sensitive to the problems with getting approval from ADP so that the cost is covered by OHIP. They have some additional paperwork to fill out for ADP to justify the need for apap.

If you are willing to buy the apap without a claim to ADP, discuss that with your sleep doctor when you get your prescription. He may not see the need for an apap but might be willing to prescribe it in this circumstance. However, why bother when you can buy an apap with a cpap prescription and for a much lower price from cpap.com!

it would've been nice if I went through the process as you did (being right after the results for first sleep test). I had to wait 3 weeks before I had an appointment with a DME. I didn't have a choice either, I guess they setup a DME that they dealt with in the past, and I didn't find them very helpful. I guess I'm kind of lucky that my friend lent me his machine for the time being so I can get used to the idea of a cpap machine (even though it was very basic machine/mask). His pressure was set for 6cm while my prescribed pressure is 7.

As I said in my other post, tomorrow I have an appointment setup for another DME, and <crossing fingers> they seem to be more helpful already (at least over the phone). My titration study is setup for June 8th, so I'll have about 3 weeks to get used to loaner cpap machine with my prescribed pressure and hopefully a more comfortable mask, but should be plenty of time for me to get "accurate" results.

I don't think I'm so hung up on getting an apap now... after talking to another member on cpaptalk.com I'll play by ear... if I need one and I'm eligible (based on Ontario's requirements) then ok! if not, it's not the end of the world, people have had their OSA controlled without apap's before they even existed... It's not like they will fudge the results so I DON'T get an apap (at least I don't hope they do). Also, my wife's insurance will cover the remaining amount that my insurance and ADP won't cover, so essentially I will /can get my first cpap machine for "free".

Fitdiculous wrote:it would've been nice if I went through the process as you did (being right after the results for first sleep test). I had to wait 3 weeks before I had an appointment with a DME. I didn't have a choice either, I guess they setup a DME that they dealt with in the past, and I didn't find them very helpful.

My situation, straight from sleep doctor to the DME office was far less than ideal. Still reeling from the diagnosis of OSA, sleep deprived, and trying to figure out what OSA means, I was ushered into a DME who's motivation is $$$$. I had no say on which DME I wanted to use, and no time to consider my needs or wants. The relationship between the sleep doctor and the DME was way too comfortable in my books. It had all of the earmarks of a classic conflict of interest.

After my titration study I discussed this concern with my sleep doctor. He seemed to be taken aback by it and explained that his clinic uses 7 different DMEs who take turns in the clinic. He provided me a copy of the list. I sometimes think that his agreement to prescribe an apap for me, as I had requested, was based in part on my concerns about the conflict of interest in his business model.

It would have been far better for the sleep doctor to give me an interim prescription for a loaner cpap and mask to take to the DME of my choice. He also could have given me a list of DME's who operate in the area, and also a link to cpaptalk and a few other sources for research purposes.

You've got a leg up on this one because you're here in advance and you're asking questions. An excellent start!

Hose_Head wrote:

Fitdiculous wrote:I actually have an appointment tomorrow with a different DME and I asked them if they provide loaner machines/masks, and to my surprise the person I was speaking to say they do! and of course at no extra charge... they MAY even be able to loan out a machine longer than a month (since I won't know the results of my 1st titration until early July).

I'm not 100% sure how long I'll be able to have the mask.. maybe a week? which should allow me to try 4-5 different masks before I decide on knowing which one works best for me....

so you're saying to just bite the bullet and buy the 1st mask from the DME and subsequently get replacements through an online vendor?? I have to double check, but I think my insurance covers replacement masks every 6 months... I'm going to try and see if the basic mask that they provide for you (within the package) can be "deleted" and credited towards an upgraded mask as well.

what other questions SHOULD I be asking tomorrow with this other DME?

This is good news!

Just be upfront with your DME about what it is that you need and want to do. Tell them that you need a cpap and mask to get you through until such time as you are ready to buy a machine. That will be after you meet with your sleep doctor to go over the results of the titration study.

I'm not recommending that you buy a cheap mask, up front. That's what happened to me because I didn't know better. As I said, "at least it was inexpensive".

Check with your private insurance. They may cover you for two masks up front. Mine did (in my first month, I bought both an activa and a swift II mask) and my insurer, Great West Life, paid 100% of both. I did not press my luck by submitting a claim for that $60 mask, although I guess it's possible that it would have been covered, too.

Questions for the DME?

Ask about the different machines that they sell. Ask to see them and to experience them (while wearing a mask) to check sound levels, ease of use, etc.

Check out the operation of the humidier; how to fill it; how to clean it

Check out different masks while in the store. My DME will allow you to try them on and "power them up".

Ask about availability for purchase of data card readers and software! (My DMEs just about choked on that one! - I purchased online)

I recommend reading as much cpaptalk as possible. It seems that few on this board (myself included) have much confidence in what DMEs tell us. They have a terrible conflict of interest given that their primary motive seems to be maximizing profit and minimizing work for themselves.

That's a pretty negative image of DMEs, I know. It's entirely unfair to the good ones out there. I just wish I knew who they are!

I'll be as honest as I can to the DME's as I can... but I won't mention to the one I'm going to tomorrow that my friend has lent me his machine... They may not want to loan me a machine for longer than the month period.

My insurance company will not cover any masks, nor will my wife's. I still have to confirm with mine what it means by "reasonable amount" as they will cover a replacement mask every 6 months but only up to a "reasonable amount" ... my wife's insurance company won't cover masks period, but will cover the rest of the machine's cost (and I believe extended warranty etc) but again only to a "reasonable amount"...

I've read so much on cpaptalk! it's crazy how much I have found out in a week... I definitely feel a lot more comfortable on how to proceed than before... still a bit overwhelming, but a lot better... I wonder if my insurance will cover data card readers? I'm pretty sure DME's won't sell software though... at least not to the "average joe"

Hose_Head wrote: My situation, straight from sleep doctor to the DME office was far less than ideal. Still reeling from the diagnosis of OSA, sleep deprived, and trying to figure out what OSA means, I was ushered into a DME who's motivation is $$$$. I had no say on which DME I wanted to use, and no time to consider my needs or wants. The relationship between the sleep doctor and the DME was way too comfortable in my books. It had all of the earmarks of a classic conflict of interest.

After my titration study I discussed this concern with my sleep doctor. He seemed to be taken aback by it and explained that his clinic uses 7 different DMEs who take turns in the clinic. He provided me a copy of the list. I sometimes think that his agreement to prescribe an apap for me, as I had requested, was based in part on my concerns about the conflict of interest in his business model.

It would have been far better for the sleep doctor to give me an interim prescription for a loaner cpap and mask to take to the DME of my choice. He also could have given me a list of DME's who operate in the area, and also a link to cpaptalk and a few other sources for research purposes.

You've got a leg up on this one because you're here in advance and you're asking questions. An excellent start!

Now that I think about it you got a point... I think I would only THINK it's better knowing what I know now... just get all that stuff over with instead of multiple appointments and what not.... I still have that similar feeling that you have with respect to the conflict of interest.... even though my sleep lab said they have no affiliation with the original DME that I went to...

when your doc provided you with the prescription for the apap what did it say? I was told that you had to have a difference of at least 4cm H20 between your supine position and side position? did he botch those figures? my sleep clinic told me that OHIP not only requires the prescription but also DETAILED proof from the clinic... does ADP cover a certain amount? I also heard it was up to 75% of the cost of the apap machine (what is that capped at?)

Fitdiculous wrote:

dsm wrote:
Hmmmm,

Interesting. My 1st reaction is - sheesh - only 7 CMs to deal with an AHI over 60 !!!. But you don't seem excessively overweight (perhaps only a tad - having been heavier that that myself )

Yes, I would ask for an Auto - Just very hard to believe that 7 CMs can do anything but resuscitate a mouse (maybe a big mouse )

At least an Auto will help you validate hwere you spend most of the night (pressurewise).

Good luck

DSM

so 7 is just a guess or "safe" guideline for these doctors to use then huh? I wouldn't consider myself overweight by any means! I have gained weight over the last 4-5 years, but I like to attribute that to working out, at least a part of it ... I haven't changed in height since puberty, but I had always been struggling to gain weight up until 25-26 years old.... I was 155-160 soaking wet... but for the most part when I did start working out 4-6 times a week and just eating A LOT more, I slowly got to where I want... at least mass wise... could I lose a few lbs? sure, why not... but I certainly don't think it made/makes my OSA THAT much more bad. My Dr. said I've had OSA for a LONG time, probably since childhood, as it's due to the shape of my jaw, size of tongue and now obviously "looser" lower pallet. I don't doubt losing some weight will help, but at an AHI over 60, it SEEMS pretty bad

I just want the best machine I possibly can get... I'm not trying to "cheat" the system or anything like that... just looking out for my health

Fitdiculous,

The difference in cost between an auto / cpap is not big - but, to a DME it is which level of profit they can swing on the whole deal. That is understandable, but from your point of view get what the system will allow. If that covers an Auto then by all means go for it as you can use it to monitor your changing needs over time. Weight loss/gain does make a small difference (in my case going from approx 200lbs to 187lbs really only changed my titration by 1 CMs).

7 CMs is still a very low pressure number & I would be very interested in hearing how you go with pressure that low & an AHI of 60+ - if it works, it will be an eye-opener for me.

You have come to the right place to get support & am sure you will learn quickly from the many helpful folk here.

Cheers

DSM

Fitdiculous wrote:when your doc provided you with the prescription for the apap what did it say? I was told that you had to have a difference of at least 4cm H20 between your supine position and side position? did he botch those figures? my sleep clinic told me that OHIP not only requires the prescription but also DETAILED proof from the clinic... does ADP cover a certain amount? I also heard it was up to 75% of the cost of the apap machine (what is that capped at?)

I'm not really certain what the doctor wrote on the forms to ADP. I never saw his report to them. I could ask for it, but haven't asked for it. The blank ADP forms are available on the internet: google ADP ontario and surf from there. Also look for the ADP FAQ.

ADP pays for 75% of the cost of both cpaps and apaps. For an apap, the approved cost is $1585 of which ADP pays $1188.75. My insurance paid 100% of the balance.

well today I had an appointment with a local DME, and got a loaner machine/mask. Just a basic Fisher & Paykel 600 series and a Swift LT mask.... I wasn't shocked with the level of service when I got there... better than the last, but the whole appointment seemed rushed... seems like if I want the S8 Elite II I'll have to get a "standard" package (vs. basic) which includes all that stuff that's not really needed (mask cleaner, filters for a year etc)... I actually left without getting the full breakdown of what else it included... it's another $410 I believe (on top of the $1040 max for the "basic" package)

At least I have the loaner machine for 8 months so I'll get used to it at the prescribed pressure and try out different masks.... I guess there's not much more I'll need to do until my titration and results but find a mask that works eh?

I'm not so caught up with getting an apap... the RT actually told me in her "20+ years she has only seen 2 apap's prescribed" DME's/ADP must not like paying for them... I found out from another user the criteria is quite strict now (may have changed?) you have to have a base pressure of 10cm and an INCREASE of at least 4cm in back OR REM sleep.

Fitdiculous,

I'd say that the 7 cm pressure is to acclimatize you to the machine before your Titration. My sleep doc did the same right after my diagnostic study, wrote 6 cm pressure. (Of course, since I felt like I was suffocating with that low pressure, these forum folks showed me how to turn the pressure up to 8 so I could breathe. Before the month was out I upped it again to 10 where I felt comfortable breathing. Hey, a doc is a "service" that I pay for; I listen to his guidance then do what I think is best for me!)

I hope you will be able to get an AUTO because you will have the best of both worlds: fixed CPAP - AND - AutoPap. An auto will also be FULLY DATA CAPABLE (more than just a data card that reads compliance), ie, it will allow you to use Software to monitor your leaks, apneas, and hypopneas on a daily basis so you can tweak your pressure to what works best for you . . . today, next month, next year, and beyond.

Good luck,
Joy

I really like the idea of patients getting loaner machines as soon as they have a PSG. I understand from this thread that this is done to allow them to get used to the process before the titration study.

I assume the setting of 7 cm pressure is selected because it is low enough to rarely induce central apneas but high enough to give you the feel of what it is like to breathe under a little pressure.

An APAP machine is NEVER overkill. It provides all of the information you need to make sure you are getting the appropriate treatment. An APAP can be used as a CPAP but not vice versa so always get the most versitile machine you can.

I want to thank everyone for all their help, I'm re-posting my original (first) sleep test results with the second test (first titration) in bold

- slept within 11.3 minutes and for 5 hours and 13 mins with efficiency of 72.4% (normal: >than 80%) -- slept within 1.6 minutes and slept for 6 hours and 54mins, sleep efficiency of 87.4%
- Stage 1 Sleep: 16.3% (normal: 4.44%) -- 7.0%
- Stage 2 Sleep: 68.3% (normal: 45.54%) -- 50.3%
- Stage 3 Sleep: 0.8% (normal: 6.21%) -- 10.1%
- Stage 4 Sleep: 7.3% (normal 14.88%) -- 6.2%
- REM Sleep: 7.3% (normal: 28.00%) and a REM sleep latency of 228 minutes (normal: 90 to 120 minutes) -- 26.4% and REM Sleep Latency of 83.5 mins
- Had 2 REM periods and 58 awakenings during the night -- Had 4 REM periods and 38 awakenings during the night
- Had 275 obstructive apneas and no central apneas of which the duration of the longest event was 28.1 seconds
- Had 49 obstructive hypopneas of which the longest was 33.0 seconds in duration
- Gave an overall AHI of 62.0 per hour (normal: <5 per hour) -- AHI at 6cm was 3.6/hour
- AHI in supine position was 71.7 and 57.4 per hour in REM sleep
- mean blood oxygen saturation overnight was 94% and decreased to 88% during respiratory events -- 96.5%
- Loud snoring observed overnight
- EKG showed normal sinus rhythm averaging 63.1 beats per min, no arrhythmia's observed -- 66.0 beats per min
- 31 spontaneous arousals, 138 respiratory arousals and no periodic limb movement arousals giving an overall arousal index of 32.3/hour -- 55 spontaneous arousals, 25 respiratory arousals and 15 periodic limb movement arousals giving overall arousal index of 13.8 per hour


Considering these results I was going in hoping that it would be "worse" so I could qualify for an APAP ... however, it wasn't as bad as I thought?? is there any part of these results that I should be concerned with? I have gotten used to the loaner machine from my DME (an older F&P machine) and the the Swift LT mask and will most likely be going with the Resmed S8 Elite II with the LT mask... problem is, I don't feel SIGNIFICANTLY "better" during the day... is it not supposed to be like a night and day difference?