ASV vs. BiPAP or DME provider vs. Insurance Company

Hello again. I am starting this on a new thread due to issues on the previous thread. I am repeating a lot here that I have already posted, in some cases because I have more information in other cases just because I like to write really long posts. I have to say that I have learned a heck of a lot in the last couple of weeks and I thank everyone here for that. I will start back at the beginning.

In the last couple years, I have felt more and more run down. I have a hard time staying awake, and I have a hard time focusing and concentrating on a task. I decided to seek treatment about 6 weeks ago and called a local sleep clinic. They were very nice and I like my doctor.

I was diagnosed with obstructive, complex and central sleep apnea. Untreated I take a 4-5 breaths and then stop breathing anywhere from 40 seconds to over a minute. The cycle repeats continuously for an hour or so and then stops for sometimes up to an hour. Then it starts again. It may have something to do with sleep stages but I don’t have a home EEG (yet) so I cannot conclusively tell. During these events, my oxygen saturation levels (I have been tracking them for a couple of weeks now) look awful, typically bouncing from around 95% to the low 80’s. I don’t snore much, I just periodically take a few huge deep breaths and then stop. I have no idea how many years this has been going on.

I have done three sleep studies in the last month. None of them were particularly good experiences, and I did not get anything close to a typical night’s sleep. All three times, I felt like I was laying there half awake for most of the night. I am concerned about the integrity of the data, and the amount of actual sleep time that was logged.

I have received written reports on all three nights as well as printouts from my PSG. I found the results somewhat surprising. The EEG says that I was in N2 stage sleep most of the time. I recorded almost no N3 sleep and very little REM sleep. Under CPAP my breathing does not really improve, so that is pretty much out. Under BiPAP all sorts of crazy things happen. At 15/13 things did not improve. At 17/13 things everything seemed to go wildly unstable, and I had central apnea events that lasted over two minute sending my O2 sats oscillating down to 70%.

On the third night, I was only on three different pressure levels the entire night. 12/7, 14/9, and 16/9. Over the night, I logged 20 central apnea events and had a total AHI of 6.1. The central events seem to occur in clusters. That is a dramatic improvement but it is still not ideal.

I can’t really tell from the plots that any of those pressure setting was really any better at eliminating the central apnea events. At 12/7, I had the highest index at 28, but I only had 12 minutes of test time in that range. At 14/9 I had a total AHI of 6.5 with 195 minutes of test time. I had no central events and AHI of 0 at 16/9 with 101 minutes in that range. The obvious conclusion is that 16/9 is some sort of magic number and I should just use a simple BiPAP machine at that setting and everything will be great. But I am more skeptical than that.

From my own pulse ox logs, even untreated I can sometimes go for over an hour with very stable breathing, at least stable enough so that no measurable desaturation events occurred. And 2cm of water isn’t a lot of pressure change. After seeing the two minute plus central events on one set of BiPAP pressures and complete absents of central events on another set of pressures, I have no doubt that the triggering of my centrals is very dependent on pressure, but I have lingering doubts that good long-term control can be achieved with a fixed pressure setup. I just don’t think there is enough data yet, and the problem is that the data is expensive.

I have already done three sleep studies. Based on my insurance ‘eligible charges’ that is $1740 worth of data so far. At the uninsured ‘submitted charges’ rate, that is nearly $12,000 worth of data. It seems silly to pay for thousands of dollar worth of data to help make hundreds of dollars worth on desicions.

My doctor prescribed a BiPAP machine with a back up rate. He had initially prescribed an S/T (spontaneous / timed) machine rather ASV (Auto or Adaptive Servo Ventilation) machine. His logic was that I was not a good candidate for CPAP, I got significant improvement with BiPAP therapy but due to these occasional unstable breathing episodes I need a machine with a backup rate. I asked him why at S/T machine and not an ASV machine, and his response was that he really like the ASV machines, and that I would probably get excellent therapy from an ASV but it was probably overkill and that the S/T machines were less expensive and easier to get insurance coverage for.

There was nothing wrong with his decisions for therapy, but his insurance information was a little out of date. As it turns out, Blue Cross Blue Shield of Alabama pays exactly that same amount for either an S/T or an AVS machine ($4400) and both machines retail for the same amount at the DME provider ($5400). The criteria for coverage for either an S/T or an AVS machine is that one has to show that they are not a candidate for CPAP, that they are a good candidate for BiPAP and that they have ‘failed a BiPAP trial’.

The ASV machines are the current ‘gold standard’ for treating complex / central apnea that does not fully respond to straight BiPAP. The S/T machines are capable of treating complex apnea, but are mostly for people that are not a good candidate for ASV. For example, people suffering from COPD, Obesity Related Hypoventilation Syndrome or other conditions where they simply are not getting enough air at their natural breathing rate.

After bringing this to his attention, my doctor agreed to change the script to a ASV if I wanted to try that instead.
But there is a catch. My DME provider will not order either machine. The reason they will not order the machine is that my slime bucket insurance company, Blue Cross Blue Shield of Alabama, will not pre-authorize it, and my DME provider is afraid they will not get paid. The clause in their coverage state that I have to have ‘failed a BiPAP trial’ but they give no explanation as to what constitutes a trial, and what constitutes a failure of such a trail. Blue Cross absolutely will not talk to me (don’t mind me, I just pay the bills) and says that all questions must go between the DME provider and their claims department. The DME provider keeps going back to my doctor for more note, my doctor sends them, they look at them but it is never enough. And in the mean time I am going without medically necessary treatment. However, in a super slimy cover-you-ass-clause, Blue Cross says that they make no medical judgment about treatment, and that if treatment is medically necessary it should be provided without regards to coverage.

So I am stuck, and I am not sure what to do. I want to start therapy. I don’t care at this point if it is just on a simple BiPAP machine and it is suboptimal. I am a really not functioning well and I think the sleeping issues are a major part of it. Even if the sleeping issues are not the main problem, I want to rule them out. However, I don’t want to end up having to pay a $500 deductable plus 20% on two machines, and I shouldn’t have to. I don’t mind so much making my portion of the payment on the ASV machine and finding out that I didn’t really need it. I wonder what the rental of a data-capable BiPAP machine would be for a month, and if that is even a possibility. No one has offered, maybe I should bring it up. I am tired and frustrated.

cnaumann wrote:, Blue Cross Blue Shield of Alabama pays exactly that same amount for either machine ($4400) and both machines retail for the same amount at the DME provider ($5400). ... . However, I don’t want to end up having to pay a $500 deductable plus 20% on two machines,

if those numbers are right, then you're looking at 1380 ish for an asv.

secondwindcpap.com has resmed 36037 vpap adapts listed for 1300.

same for 960 autosv.

and you wouldn't have to deal with the insurance crap, and 'failing bilevel' and compliance checks.

just a thought.

Because your situ is complex, I think you will be better off using a DME - hopefully a good one.

You may ask your insurance if you need to change machines if there will be another co-pay. Many insurances have a contract with DME that won't allow for new charges.

So it may be to your advantage to start with whatever the insurance will cover, ST or BiPap, just to get some therapy for you. You seem like you can then help steer your doc to the best treatment plan for you.

Where you may run into problems is when this year ends - will your deductible start over again?

Do the math...allow some $$ for hassle and aggravation IF (big if right now since they are putting up road blocks) your could get your insurance to pay for either the PR S1 model 960 Auto SV or the S9 Adapt model 36038. What would be your out of pocket costs?

Secondwindcpap.com is showing a PR S1 Auto SV model 960... brand new open box, zero hour machine with full 2 year warranty...for $1,429. This includes the humidifier. I don't know if it includes the heated hose upgrade features but at the most that is $75 if it doesn't have it and is deemed necessary.
http://www.secondwindcpap.com/Open_Box.html

They sometimes have gently used S9 Adapts...both 36007 and newer 36037 machines for around $1249. I don't know what they have at the moment....for those it's best to check with them directly. They don't always show them on the official list.

The problem with the $500 deductible is that it is already November, and if I did buy a machine and it did not work out it would probably be next year and a new $500 deductible. However, the deductible would apply to masks as well, so I will pay more out of pocket for the mask(s) if I buy second hand.

The open box / second hand route sounds really good. I am going to make some calls. Unfortunately It does not meet my tertiary goal of bringing as much pain and suffering to my insurance company as possible. Karma, I guess I just have to believe.

Guest, as far as talking to anyone about what is covered, that is kind of the whole issue. Blue Cross makes you buy first, ask questions later. They absolutely will not talk about coverage a priori. And they will not talk to me about coverage at all. Those number I quoted come from a reliable source, but they did not come from Blue Cross, Blue Cross will not disclose those numbers. It is buy it, then we might repay you some secret amount.

cnaumann wrote:Unfortunately It does not meet my tertiary goal of bringing as much pain and suffering to my insurance company as possible. Karma, I guess I just have to believe.

I actually do understand...but there comes a time when we have to decide if causing the insurance company any grief is worth it or if we are just cutting our nose off to spite our face.
There's nothing stopping you from using a DME for masks and other supplies even if you buy the machine privately.
Of course that doesn't help out with the deductible or mask purchases right now.
After the first of the year the deductible starts over again so masks will cost the same no matter what.

What mask were you wanting to use that you would have to buy? Or do you just want to be able to utilize whatever the DMEs mask swapping policy is?
I might have a mask you could just have...free except for maybe postage to help me out since I mail out quite a bit of stuff...I have some that are brand new..not even opened and some opened for fitting and discarded ad some gently used (but look brand new) for a couple of nights and it didn't work out.

If we could get you by with a mask until after the first of the year then any mask purchases would go towards the deductible and help out with further expenses.

So let me know if you have any idea what mask you might be willing to try. I might have one.
Oh...and just because you are using that high dollar machine at probably higher pressures doesn't mean that the only choice is full face mask because of pressures. I am using the S9 Adapt with nasal pillows and routinely see the pressures go to around 22 cm.
Now if you can't breathe through your nose...then you need a full face mask but don't assume that just because of the pressures that you are stuck with FFM.

When I was prescribed my ASV, my Order was faxed over to my DME. After 2 months of waiting on the DME to fill the order, I called them and they told me my insurance had denied it. When I called my insurance, they said that a claim had never been submitted. I went back to the DME with my new information and they told me that I did not meet their supplier's criteria for needing one, therefore they never contacted my insurance.

Several calls later, my insurance told me to take my prescription to another DME that I was contracted with. I did, and had my brand-spankin' new ASV in my hands a few days later.

Moral of the story: if you don't like the DME's way of handling your health needs, find another one who will!

The mask I used in the sleep study was a large Air Fit F10 full mask. I will need a full mask occasionally due to seasonal allergies. That is what I will probably initially purchase. I was having a little trouble opening my mouth with the nasal mask during the sleep study but I think I can learn to keep my mouth shut.

Of course, I spent part of the time trying to figure out if let the air blow in my nose and out my mouth and at the same time and still exchange enough air in my lungs so that I would not actually have to breathe... that did not work so well, but I have not given up on it. I was also trying to see if I could whistle continuously. Again, no success but I might just need more practice.

I would like to use a nasal pillow mask. I really don’t like having anything around my nose.

That ‘gently used’ ResMed S9 Adaptive SV on Secondwindcpap.com for $1000 seems like too good to pass up. That is $400 less than the open box PR 960 BiPAP Auto SV Advanced. Even with a mask that will be less than my out-of-pocket through the DME.

M’ohms, that is EXACTLY what is happening in my case. I am pretty sure that my DME has not actually talked to my insurance company. Only I didn’t give them a month, I gave them a day and a half and then started with daily calls.

cnaumann wrote:I spent part of the time trying to figure out if let the air blow in my nose and out my mouth and at the same time and still exchange enough air in my lungs so that I would not actually have to breathe... that did not work so well,

simply not possible, too much deadspace in the trachea and bronchi between your nasopharynx where the air cycles from your nose to mouth and your alveoli where co2 and o2 are exchanged with your blood.

cnaumann wrote: That ‘gently used’ ResMed S9 Adaptive SV on Secondwindcpap.com for $1000 seems like too good to pass up. That is $400 less than the open box PR 960 BiPAP Auto SV Advanced.

the 1000$ vpap adapt is the older version (36007) without the autoasv function, meaning it can't vary the base epap pressure, though, of course, some people don't like that feature, so it's optional.

simply not possible, too much deadspace in the trachea and bronchi between your nasopharynx where the air cycles from your nose to mouth and your alveoli where co2 and o2 are exchanged with your blood.

Yeah, but if I could just get some turbulence going... Oh well, that still leaves learning to whistle.

the 1000$ vpap adapt is the older version (36007) without the autoasv function, meaning it can't vary the base epap pressure, though, of course, some people don't like that feature, so it's optional.

Thanks. I will do a little more research before ordering. I like the ResMed machines because they seem to have more information publicly avaible such as detailed titration guides. I like the PR machines because it seems like there is more to fiddle with. I am pretty sure that I will get good results with anything.

I figured it would not do any good to place the order before Monday anyway.

cnaumann wrote:

simply not possible, too much deadspace in the trachea and bronchi between your nasopharynx where the air cycles from your nose to mouth and your alveoli where co2 and o2 are exchanged with your blood.

Yeah, but if I could just get some turbulence going... Oh well, that still leaves learning to whistle.
[*]

the 1000$ vpap adapt is the older version (36007) without the autoasv function, meaning it can't vary the base epap pressure, though, of course, some people don't like that feature, so it's optional.

Thanks. I will do a little more research before ordering. I like the ResMed machines because they seem to have more information publicly avaible such as detailed titration guides. I like the PR machines because it seems like there is more to fiddle with. I am pretty sure that I will get good results with anything.

I figured it would not do any good to place the order before Monday anyway.

here's some more food for thought wrt the two different machines... this isn't asv specific, but general PRS1 vs resmed.
viewtopic.php?f=1&t=99737&p=928086&hili ... er#p928086

I've since added to the list with the following:

• better carrying case (resmeds come with a padded travel case, PR it's extra.
• all s9 and as10 units are heated hose ready, that's extra on some 60 series pr units.
• manuals are MUCH better and more informantive on the resmed

I had to go the Bipap first because of insurance company issues rather that going straight to ASV even though the doctor didn't think the Bipap would get me very good results. Cpap wasn't even an option. Fortunately for me I'm somewhat over insured using Tricare for secondary coverage which means I don't every have a copay. I ended up using the Bipap for about 6 months and then switching to a Vpap. It took a year and a couple months before the machine was fully paid for.

SeekSleep wrote:I had to go the Bipap first because of insurance company issues rather that going straight to ASV even though the doctor didn't think the Bipap would get me very good results. Cpap wasn't even an option. Fortunately for me I'm somewhat over insured using Tricare for secondary coverage which means I don't every have a copay. I ended up using the Bipap for about 6 months and then switching to a Vpap. It took a year and a couple months before the machine was fully paid for.

vpap is bipap, just by a different company. both are respective trademarks for bi-level

I faxed my scripts up to secondwindcpap this morning. Two hours later I called Mark and after 15 minutes on the phone the DS960 and F10 mask are on their way. Simple, fast, painless, and honestly not that much more out of pocket. The DS960 may be overkill, but I belive that it has the best chance of providing optimal therapy.

A HUGE thank you to EVERYONE who replied, especially Pugsy, Shane, and Palerider. There is no way I could have gotten here on my own.

Now to start getting better sleep!

cnaumann wrote:I faxed my scripts up to secondwindcpap this morning. Two hours later I called Mark and after 15 minutes on the phone the DS960 and F10 mask are on their way. Simple, fast, painless, and honestly not that much more out of pocket. The DS960 may be overkill, but I belive that it has the best chance of providing optimal therapy.

A HUGE thank you to EVERYONE who replied, especially Pugsy, Shane, and Palerider. There is no way I could have gotten here on my own.

Now to start getting better sleep!

that's just absolutely *awesome*!

hopefully you'll take to it like a duck to water, or like pugsy did to hers, and the friend I have that has CHF took to his adapt.

I don't know the specifics of the 960, since all my experience has been with the s9 adapt, but, the general principals are close enough, and there's some very experienced folks here that use the 960.

I'd start reading up on old posts from JohnBfisher, and others, the more you've read about the 960 when you get it, the better you'll be prepared to bend it to your will when you get it