UPDATED: ADP Criteria to qualify for APAP/BIPAP/CPAP

[ChrisC]

Hello!

Just was talking to my sleep lab about the possibility of changing my CPAP prescription for an APAP. I explained, during my initial consultation with the sleep doc, that I have had a small spontaneous pneumothorax and he was the one that first mentioned APAP. I just brought this up with the co-ordinator at his office that is handling my case, and she said there was some criteria I had to meet to be eligible for ADP funding for an APAP. One criteria is that I need at least a 10cm titrated pressure, which I do.

Anyone know the other criteria ADP expects for you to qualify for APAP?

[Hose_Head]

Hello!

Just was talking to my sleep lab about the possibility of changing my CPAP prescription for an APAP. I explained, during my initial consultation with the sleep doc, that I have had a small spontaneous pneumothorax and he was the one that first mentioned APAP. I just brought this up with the co-ordinator at his office that is handling my case, and she said there was some criteria I had to meet to be eligible for ADP funding for an APAP. One criteria is that I need at least a 10cm titrated pressure, which I do.

Anyone know the other criteria ADP expects for you to qualify for APAP?

I don't know what the criteria are, but I went that route and got an APAP paid by ADP. The sleep doctor is the one who fills out the forms and sends them to ADP. I never saw them.

If you can qualify, it's my recommendation that you get the APAP. The cost is $1585 of which $1188.75 is paid by ADP.

There is a FAQ on the ADP web site.

[ChrisC]

Well, sometimes it pays to be a DME registered with ADP! We just do mobility, but I was able to access the administration manual for respiratory devices. I answered my own initial question.. for APAP, you have to have a minimum of 10CM pressure and have a change of a minimum of 4CM when switching from your back to your side. Thankfully, I remember moving to my side during the night of the PSG and hope the technician fiddled with the pressure when I did.

The following is the criteria for all XPAP machines under ADP. Enjoy!

7 POSITIVE AIRWAY PRESSURE SYSTEMS

Auto-Titrating Positive Airway Pressure (APAP)
Bi-Level Positive Airway Pressure (BPAP)
Continuous Positive Airway Pressure (CPAP)

7.1 Medical Eligibility Criteria

Only individuals with a diagnosis of Obstructive Sleep Apnea Syndrome
(OSAS) are eligible to apply.
See Section 2 for general eligibility criteria required to access the ADP and
the Respiratory Devices Category.

7.2 Acceptable Evidence of Medical Eligibility

To receive funding assistance for Positive Airway Pressure Systems, an
individual must be assessed at an ADP-registered Sleep Laboratory. The
assessment must include a Level 1 Polysomnography, showing evidence of
OSAS during sleep and the presence of significant symptoms or medical risks
without treatment, and the absence of symptoms or risks with treatment. The
prescriber may be required to provide a written copy of the Level 1
Polysomnography.

7.3 Bi-Level Positive Airway Pressure (BPAP) Systems

Individuals requiring BPAP systems without timers must meet the eligibility
criteria outline in Sections 7.1 and 7.2 above and the medical eligibility criteria
outlined in Section 7.3.1 below. Special ADP authorization is required when
requesting funding assistance for BPAP Systems. See Section 9.
7.3.1 Medical Eligibility Criteria for BPAP
The following individuals are eligible:

(i) Individuals with polysomnographically documented sleep apnea who,
despite Continuous Positive Airway Pressure (CPAP) of 15 cmH2O or
greater, exhibit one of the following:
1. Nocturnal hypoxemia (O2 saturation <88%)
2. Nocturnal hypercapnia (PaCO2 >50mmHg) despite three or more
months of sustained CPAP therapy, and in the absence of significant
underlying COPD which could account for the persistent hypercapnia
3. Apnea/hypopnea index >10
(ii) Individuals with polysomnographically documented sleep apnea in whom
CPAP > 15 cmH2O resolves the physiological abnormalities listed under
(I) but who are unable to tolerate this pressure.
(iii) Individuals with polysomnographically documented sleep apnea who
1. Are unable to tolerate any level of CPAP
or
2. Continue to complain of excessive daytime sleepiness despite
resolution of physiological abnormalities when treated with CPAP,
and the exclusion of other conditions that could cause daytime
sleepiness (e.g. narcolepsy); will be considered on an individual
basis.

7.3.2 Acceptable Evidence of Medical Eligibility

The assessment of an individual for a BPAP system must be completed by a
physician with an expertise in respiratory physiology and experience in
mechanical ventilation.
The prescriber must include in the request for special authorization, Section
9, evidence that the medical criteria for a BPAP system has been met.
When requesting authorization for funding for an individual who meets
medical criterion 7.3.1(i) above, the prescriber is required to give detailed
information, including the duration of the trial with CPAP and the pressures
required.

NOTE: Where remoteness and lack of access to a sleep laboratory is a
factor, assessment using transcutaneous PaCO2 under the direction
of a respirologist will be considered. However, there must be
documentation of a previous assessment through a registered sleep
laboratory.

7.4 Auto-Titrating Positive Airway Pressure (APAP) Systems
Individuals requiring APAP systems must meet the eligibility criteria outline in
Sections 7.1 and 7.2 above and the medical eligibility criteria outlined in
Section 7.4.1 below. Special ADP authorization is required when requesting
funding assistance for APAP Systems. See Section 9.

7.4.1 Medical Eligibility Criteria for APAP
The following individuals are eligible:

Individuals with polysomnographically documented OSAS where there is a
change in pressure of a minimum of 4 cmH2O on a prescribed fixed CPAP
level of 10 cmH2O or more.
The change must occur between REM vs. NREM sleep or supine vs. sleeping
on their side.
7.4.2 Acceptable Evidence of Medical Eligibility

Special ADP authorization is required when requesting funding assistance for
APAP Systems. See Section 9.
The prescriber must include in the request for special authorization, Section
9, evidence that the medical criteria for a APAP system has been met.
When requesting authorization for funding for an individual who meets
medical criterion 7.4 above, the prescriber is required to give detailed
information.

7.5 Funding for Positive Airway Pressure Systems

A Positive Airway Pressure System (CPAP, APAP, BPAP) includes all the
following items:
(i) a positive airway pressure device;
(ii) a heated humidifier;
(iii) a basic mask and headgear;
(iv) carrying case;
(v) 6 ft. tubing;
(vi) all necessary caps and filters,
(vii) user instruction manual.
Registered respiratory vendors may bill the client 100% of the cost for items
not included in the Positive Airway Pressure System as listed above.
Registered respiratory vendors may provide additional services to the client,
such as service packages. The vendor may offer these services to the client
at a cost separate from the funding assistance provided by the ADP.
Registered respiratory vendors who offer clients additional services must
provide the client with the option to purchase the additional services
separately and not as a mandatory service when purchasing a system.

[Emmy1]

for APAP...

Individuals with polysomnographically documented OSAS where there is a change in pressure of a minimum of 4 cmH2O on a prescribed fixed CPAP level of 10 cmH2O or more.
The change must occur between REM vs. NREM sleep or supine vs. sleeping on their side.

Thank you for that information.

I guess I'm on my own if I want to get APAP. I cannot sleep on my back at all because of severe back pain (spinal degeneration and nerve impingement). I haven't even tried for over ten years. Now, when I lie on my back for even a few seconds it becomes extremely difficult to breath> I'm sure I would need an additional 4 cm of pressure, but there is no way I could lie there long enough to actually fall asleep.

I can't turn over in my sleep at all because of extreme physical disability and weight issues. Once I choose a position I stay in that position until the pain becomes severe enough to wake me, then I turn over (with difficulty) and lay awake for about half an hour until the pain on that side becomes intolerable, then I turn back again and try to sleep. I can only sleep on one side and that one position.

My sleep lab study showed that I got no REM sleep at all, just light dozing. My pressure was around 10 or 11.

My at home titration study showed that my pressure requirement was higher once I finally did start to get deeper sleep. The readings kept going up until they reached the preset limit of 13.9, but this was not done in a lab.

I can't prove there is a difference between light sleep and deep sleep unless I go back to the lab. Since I can't sleep properly in the lab, due to intense pain, there is no point in asking for another study. At least now I know.

[BlackSpinner]

There are home titration studies which are used in Quebec. That way you sleep in your own bed with your own mask and the machine and other sensors pick up your heart beat, blood presure and O2 levels as well as the cpap pressure.

If they can do it in Quebec they should be able to do it in Ontario.

[HoseCrusher]

Emmy1, It is possible to observe different levels of sleep using a recording pulse oximeter. I wouldn't bet the bank on what level you are at based on that data, but your breathing rate and oxygen saturation do drop off with deeper sleep stages.

While not the perfect tool for the job, it may provide you with some information that can help you figure things out.