Benefits of AUTO vs standard CPAP

I have used APAP (4-20 --> 6-10 psi) for 4+ years (but lost my machine due to insurance change - using an old backup) and my new sleep MD wants to put me on standard CPAP at 7.0 psi (after a recent attended sleep study/titration). How do I convince MD that he should prescribe me APAP. My sleep doc, though young and personable, did not seem keen on the patients experimenting with their CPAP therapy.

Some of my and others' thoughts for convincing/justifying to the sleep doc why I should have an APAP*:

1. will need more pressure when I have a cold or allergy (which I am prone to)
2. will need more or less pressure depending if I drink alcohol (which I do on occasion)
3. will need more or less pressure if I sleep on my side or back
4. am planning to lose weight and it may change my pressure settings
5. sometimes I take an ambien to sleep and that will change my pressures
6. I have been using APAP and am familiar and comfortable (and compliant) with APAP
7. I want APAP and it is my therapy (and the insurance company will not know/not care) re: the difference
8. My sleep study w/ titration was done on only one night (therefore it is a snapshot) and I want to be able to monitor my own responses at different pressures (adjacent to the "optimal" pressure from my sleep study
9. I am a PhD science nerd, care about my therapy and will enjoy #8 with APAP. This kind of intellectual engagement (and extra comfort) has and will continue to help me with my compliance.

* This is partially redundant with the thread I previously started but since I included too many topics (and that thread evolved on its own), I thought I would make this more focused thread.

What insurance do you have that the rented your APAP for 4+ years? Most all insurances now more sensibly have a "capped rental/rent to own" type of purchase arrangment. Anywhere from 3 to 13 months and then the PAP becomes your sole property. The accessories, i.e. humidifier, mask, hose, etc. are usually paid in full at time of provision.

Most all insurances pay for PAP therapy by insurance (HCPCS) code, NOT by brand and/or model. An entry level PAP, a fully data capable PAP and a fully data capable APAP are all the same insurance code (e0601). The bi-levels and more sophisticated devices have an entirely different code.

Call your insurance company and ask them what local DME CPAP providers they are contracted with. Hopefully, you will have the option of more than one. Ask your insurance company how they pay for CPAP devices and accessories, is there a rental period, is it/are they outright purchases? Don't even bother to mention CPAP vs APAP.

The DME provider is going to get paid one set contracted price for that CPAP, whether they are able to pawn off an entry level PAP or you convince them to provide you w/a fully data capable CPAP or APAP. Its to the benefit of their financial bottom line if they can con you into accepting an entry level PAP or even a full data capable CPAP rather than an APAP. So many are "less than truthful" or intentionally guilty of "sins of omission" when they tell you what your insurance will and won't pay for.

Rather than ask your sleep doctor to script an APAP, ask that he include "access to Leak, AHI and AI" on your script, and while you are at it you might as well ask that he also include "full face, nasal cushion, nasal pillows or oro-nasal mask of patient's choice" as the 4 styles of mask are different HCPCS codes and some local DME providers like to take advantage of that to provide the cheaper masks rather than the mask that works best for you.

Before you commit to buying from any local DME provider "shop" your options, ask what brand and model PAP they prefer to provide, tell them the type of PAP you prefer to have, ask how lenient their mask exchange policy is, see how comfortable you are w/their RRT and determine how readily that RRT is to you if you need assistance from him/her. Having the option of more than one local DME provider gives you more bargaining/negotiating room to get an APAP instead of an entry level CPAP. Both of you MIGHT end up having to compromise on a fully data capable CPAP but the full data capability is more important than the auto titrating option. Be diplomatic, but firm, in what you want and most likely you will get what you want.

Keep in mind that most local DME providers buy their PAPs from the manufacturer that gives them the best bulk price so either be flexible on what brand of PAP you want or settle for the local providers who prefer to provide the brand you want as they will have more bargaining/negotiating room than one who prefers to provide another brand.

The APAP allows you to minimize the pressure only increasing the pressure when needed. This increases patient comfort and thus compliance.

You can make the point that any CPAP setting is a compromise.

Since using the S9 Autoset my quality of sleep has improved over my use of an Autoset T. I suspect that the updated algorithm along with the EPR setting has helped treat the Centrals that I didn't previously know I had. This is an argument for a more sophisticated machine which can be set up as an APAP or a CPAP.

The key point is that you get a APAP capable machine even if it is set up in CPAP mode Once you have the machine you can obtain the software and find out how to adjust the machine settings. Use the first months data to produce a compliance report for the doctor then starting with this base line perform an experiment to see how sleep quality varies with changes to machine setting. Depending on doctors comfort level with patient involvement in treatment you may not want to mention this option.

Your doctor may be more comfortable with patient involvement if you involve him in the experiment and agree on guidelines for adjusting the machine settings.

Failing all else you may want to find an Internet supplier or brick and mortar DME that will provide you with an APAP machine set to operate as a CPAP machine if you have a prescription for a CPAP machine. This may be a lot easier to arrange if you do not need to worry about insurance.

Assuming you enjoy numbers and research the APAP is the way to go if you want to be active in your therapy. I enjoy looking at my AHI numbers each morning, and downloading my data into my computer to determine if setting adjustments may optimize my therapy. My goal is to have a narrow range in my minimum and maximum settings. I enjoy using the EPR features of my machine (S9 Autoset). My range is currently 16-20 with EPR at 3. Which ever machine you are willing to accept should be one where you can easily adjust settings (access clinical menus and documentation) and have full detailed level downloads. If money is not an issue in your decision, get your prescription and call cpap.com and get the S9 Autoset and all the accessories. The phone price will be lower than the web site price due to the requirements that Resmed places on retailers. This thread describes part of what I went through about 45 days ago. I went to initial visits with the doctor at 3 or 4 sleep labs before doing a sleep study. This allowed me to ask questions to verify that the doctor would even write a script for APAP. Learned that many only write them for 4 weeks to help in determining your pressure for CPAP that is prescribed.

liv2kite wrote:I have used APAP (4-20 --> 6-10 psi) for 4+ years (but lost my machine due to insurance change - using an old backup) and my new sleep MD wants to put me on standard CPAP at 7.0 psi (after a recent attended sleep study/titration). How do I convince MD that he should prescribe me APAP. My sleep doc, though young and personable, did not seem keen on the patients experimenting with their CPAP therapy.

Some of my and others' thoughts for convincing/justifying to the sleep doc why I should have an APAP*:

1. will need more pressure when I have a cold or allergy (which I am prone to)
2. will need more or less pressure depending if I drink alcohol (which I do on occasion)
3. will need more or less pressure if I sleep on my side or back
4. am planning to lose weight and it may change my pressure settings
5. sometimes I take an ambien to sleep and that will change my pressures
6. I have been using APAP and am familiar and comfortable (and compliant) with APAP
7. I want APAP and it is my therapy (and the insurance company will not know/not care) re: the difference
8. My sleep study w/ titration was done on only one night (therefore it is a snapshot) and I want to be able to monitor my own responses at different pressures (adjacent to the "optimal" pressure from my sleep study
9. I am a PhD science nerd, care about my therapy and will enjoy #8 with APAP. This kind of intellectual engagement (and extra comfort) has and will continue to help me with my compliance.

* This is partially redundant with the thread I previously started but since I included too many topics (and that thread evolved on its own), I thought I would make this more focused thread.

Along the lines of Slinky's question.......HOW IN THE WORLD did they take a machine away from you that should have been paid for within the first year??????

I know you've been a forum member for a number of years, so I would think most of these arguments you're preparing yourself for should be a piece of cake. However, I do feel that most of them have large holes in the logic.

Do you have your prescription? (physical document) If so (you should have it), just buy whatever you want out-of-pocket. That way, the insurance/DME thugs won't be able to take it away from you again.

If you're a science nerd (and a previous APAP user), then you must know that APAPs respond slowly to events and if not configured correctly will provide POOR (worse) therapy (compared to straight-pressure CPAP).

In my opinion, the main advantage that APAPs have is that they CAN be run in CPAP mode.


Den

Wulfman wrote: Along the lines of Slinky's question.......HOW IN THE WORLD did they take a machine away from you that should have been paid for within the first year??????

I know you've been a forum member for a number of years, so I would think most of these arguments you're preparing yourself for should be a piece of cake. However, I do feel that most of them have large holes in the logic.

Do you have your prescription? (physical document) If so (you should have it), just buy whatever you want out-of-pocket. That way, the insurance/DME thugs won't be able to take it away from you again.

If you're a science nerd (and a previous APAP user), then you must know that APAPs respond slowly to events and if not configured correctly will provide POOR (worse) therapy (compared to straight-pressure CPAP).

In my opinion, the main advantage that APAPs have is that they CAN be run in CPAP mode.

Den

Actually, I kept my first machine which I had for several years (am using that one now but want to update). It is my second machine (S8 Autoset II) that I had to give back. DME said my insurance (Aetna) would not allow rent to own (I don't remember how long I had been renting the second machine).

I do understand how APAP works but needed to justify it. I agree with you that many of the statements have holes in logic, though some are better/worse than others.

Seems many users claim better comfort with APAP. I am not really worried that poor (incorrect or slow) APAP machine response would result in poor therapy (especially if APAP window is narrowly brackets the typical optimum pressure which I recognize approximates using it in CPAP mode). On the contrary, one could also argue the opposite (which I believe), that AUTO might more often than CPAP give you optimal pressure due to variable pressure needs due to variations in airway on different nights. Obviously, the detailed compliance data, collected longitudinally, over many patients, would tell whether APAP is more effective in reducing AHI events, in sleep quality and in comfort. I am sure that rigorous scientific data of this type exists. My sleep doc did say that studies have shown that APAP doesn't generally increase comfort.

I think that you might consider finding a sleep doc whose view on patients participating in therapy decisions are closer to your own. It's well worth the effort.

jdm2857 wrote:I think that you might consider finding a sleep doc whose view on patients participating in therapy decisions are closer to your own. It's well worth the effort.

Amen to that.

I've had three sleep doc's since I've had a data capable Auto PAP. All three doctors have been very happy with me setting up my own machine. Every time I see my sleep doc I provide print outs showing how I've been doing for the last few months prior to my appointment. My current doc has said may times, he wishes all his patients were like me.

The reason for three docs was due to 2 leaving the practice, relocated to another city.

Recently my wife joined me as a hose head. Her sleep doc read me up one side and down other because I changed my wife's prescribed pressure which lowered her AHI from over 10, to under 5. I provided her doc with a print out of her AHI using different pressures, her doc didn't even look at them, she was to busy telling me off. Unfortunately her ego got the best of her.

I've got my wife going to my sleep doc, provided printouts from her data capable machine from the various pressures we tried. My doc took time reviewing the data provided and asked a lot of questions. He showed an interest in my wife's well-being.

I did fire one sleep doc because he wouldn't help me. After my first 1 1/2 years on CPAP I saw a doc because CPAP didn't make me feel any better, I actually felt worse as time went on. I requested a sleep study, doc said no, no reason given for his decision, wanted me back in two weeks. I went on-line and read about the new data capable auto's that recently came on the market. I asked the doc for a prescription for auto PAP, offering to purchase software out of pocket, since I couldn't have a sleep study. Doc said no to a data capable auto, again no reason given for his decision.

I had a copy of my prescription for a straight CPAP which I used to purchase an auto machine on-line. It was the best $900 I ever spent, my first night with the auto was like a miracle. For the first time in 20 years I woke feeling refreshed, I was having dreams, it as amazing. The pressure of my old CPAP was to low.

Sorry for the long story, This answer probably isn't much help for you right now. It might help others. It seems doctors are now asking for the cards from data capable XPAP's but they are only getting about 7 days of detailed data off the card. The reports I provide my doc with provides a few months of data.

There are lots of very good doctors out there, I fired one because he would not help me. We fired my wife's doc as her ego got in the way of doing what was best for my wife.

Using a data capable machine and software, I was able to take my care into my own hands, when the sleep doc refused to help me. I haven't looked back, my last three doc's want me to have a machine that is data capable.

Good luck

GTO (Pontiac?) --

I just have to ask which APAP you have. My S8 AutoSet II hasn't be able to do as well for me as your has for you. And, If I might ask, what pressure range are you running?

Unless you have other medical problems, if you have a data-capable machine, know how to interpret the reports, and know how to adjust your pressures accordingly and can see good results, why do you need an OK from a Dr to tell you what you already know ? The "specialist" we saw in the beginning was useless, uninformed and gave us bad advice that I was only able to correct by learning from the experts here. My husband just sees his Internist and Cardio for his other medical treatment.

Thanks to everyone for great comments. Are APAPs the only xPAP machines capable of reporting and allowing patient access to AHI, leaks and AI. If so, it is a slam dunk/no-brainer for me.

jdm2857 wrote:GTO (Pontiac?) --

I just have to ask which APAP you have. My S8 AutoSet II hasn't be able to do as well for me as your has for you. And, If I might ask, what pressure range are you running?

At the time I was using a Respironics Remstar auto with C-Flex. The last 6 months I haven't been doing very well. Been having a lot of trouble with leaks that were gradually getting worse over time. Turns out my machine set at 15 was putting out 22. I had been using a range of 15 to 17.5, my original prescribed pressure was 12. When I first got the Auto PAP I started with a range of 13.5 to 20. But gradually raised the lower pressure to 15. My AHI was about the same but I felt better.
A few days ago I replaced my old Respironics with a new S9 Auto. I'm still getting used to it and haven't gotten back to a normal sleep pattern due to my failing Respironics. Very often I was getting up for a couple of hours in the middle of the night due to mask leaks I couldn't stop. No more mask leak problems with my new S9.
Fortunately, thanks to this forum I was able to get software so I can track my progress.

Yes the GTO is from Pontiac. I have two 69's, The Judge, and a regular GTO that has a ram air engine. I fell in love with the 69 Pontiac, I've never been without a 69 since 71. Hasn't always been the same vehicle.

liv2kite wrote:Thanks to everyone for great comments. Are APAPs the only xPAP machines capable of reporting and allowing patient access to AHI, leaks and AI. If so, it is a slam dunk/no-brainer for me.

There are other data capable machines such as BiLevel & BiPAP's.

I'm using an Auto and my wife who recently joined me as a hose head uses an Auto BiPAP with C-Flex. I highly recommend a data capable machine. With the proper software it allows you to track your progress. This allowed me tweak my settings to what works best for me. Did the same for my wife.

I barely slept in the sleep lab. I don't sleep on my back, the sleep lab wanted me sleeping my back during part of the study. It wasn't surprising to me that my pressure was wrong.
The first half of the night was to determine how bad my sleep apnea is, the second half was to determine the proper pressure. It's a one night snapshot. With my data capable machine I can check my pressure every night. I have 5 or 6 years of saved data even though I will never need to go that far back, data from 6 years ago doesn't mean much today. Other than allowing me to see if things have changed slightly over the years.

Good luck.

There are straight CPAPs that are fully data capable such as the Resmed Elite, Respironics Pro, PR SystemOne Pro, DeVilbiss IntelliPAP Info, Fisher & Paykel Icon Primo and ... I forget which Covidien/Puritan Bennet/PH Sandman.

On the other hand the Resmed Compact, Resmed Escape, Resmed Tango, Respironics Plus, DeVilbiss IntelliPAP Intro .... and others are not fully data capable.

liv2kite wrote:Thanks to everyone for great comments. Are APAPs the only xPAP machines capable of reporting and allowing patient access to AHI, leaks and AI. If so, it is a slam dunk/no-brainer for me.

Absolutely not!

Fully data-capable straight pressure CPAPs have been around for over five years (that's when I got my first REMstar Pro 2).

Here's a link to a current list of machines that 'rested gal" put together.

viewtopic.php?p=307168#p307168

Please understand that I've never had a problem with people HAVING an APAP (I own four of them).......it's just that most people (including doctors) are clueless about how they do and don't work. I've also seen too many new users have problems with or complain about getting lousy therapy when trying to use an APAP. It usually revolves around the pressure changes and mask leaks disturbing their sleep. With pressure changes, the subconscious is bombarded with those changes all night long and it takes its toll on their quality of sleep. In the instances of mask leaks, they usually adjust their masks for lower pressures so when the pressure goes up the leaks increase.


Den