? on Bi-Level and Buying Online

[Mrs. Newbie]

My husband a new Pap user was recently changed from a straight CPAP (Pressure of 17) to a Bi-Level set at 8 and 17. He could not tolerate the pressure on the straight CPAP and our DME told us Auto machines are not covered, hence the bi-level.

Problem is that he's not doing much better on the Bi-Level, he keeps using his ramp etc., and wakes through the night with some mask leaks. So it doesn't seem to be very helpful at this point, as he still is not sleeping well and not feeling any better. Last night I noticed he was back to snoring very loudly, like he had prior to CPAP, so now I'm wondering if the Bi-Level is even working to help at all. Is it normal to snore loudly on a PAP, he hadn't for the past few weeks, so that has me confused too. He hasn't called the DME as yet, but hoping he will tonight. He's not the type to complain, so I've kind of had to push him to call for changes etc., at this point I'm almost afraid he's going to say the heck with this all, since it's not exactly working....

On top of that I just found out that the Bi-Level will be billed to insurance at $400ish per month and they will pay $200ish, but that will exhaust our benefits within the next four months and then we'll be out of coverage until next year. That means we could be stuck with paying over $2400 out of pocket (@$400/mo, for the end of the rental), of course this is going to be tough on us and we know we could buy online for so much less, but would be out-of-network for us with zero coverage....so in a bit of a quandary as you can tell, especially being we aren't' seeing good results....Buying online is an option of course, but we just are not sure what to buy and what our PCP would think of that idea (haven't talked to him about it, as yet), especially since we are still hoping for some positive results so we'd have some clue what to buy???

Oh well, still taking one day at a time, but looking for input from all you "very educated" apnea people. Thanks in advance for your ideas and suggestions.

Mrs. Newbie

[NightHawkeye]

Problem is that he's not doing much better on the Bi-Level, he keeps using his ramp etc., and wakes through the night with some mask leaks. So it doesn't seem to be very helpful at this point, as he still is not sleeping well and not feeling any better.

Dear Mrs. Newbie,

You've come to the right place. Many folks here can help. However, they will need more information. What sort of mask is he using? Also, since it appears that what has been prescribed is not working, the best way to correct that is to gather additional info with a machine that collects detailed data. An APAP is not required, just a machine that collects detailed sleep data. I'm sure others will make specific BiPAP machine recommendations. Hopefully, your insurance will cover one of them.

Once your husband begins collecting data, you can look at it to see what's happening and make adjustments as appropriate. Without the detailed data, it's just a guessing game, and that often doesn't seem to work.

FWIW, it appears that most folks who come here end up staying with xPAP therapy, but adjustments seem to be required for everybody.

Hope this helps.

Regards,
Bill

[sleepylady]

Mrs. Newbie,

Is your DME sure your insurance won't pay for an APAP? Frankly many insurances view an APAP as a CPAP. The reason DME's don't want to supply them is because their profit margin is then cut way down. DME's prefer to either give CPAP's or BiPAP's. My insurance views an APAP as an automatic CPAP...that's the key. You may want to call your insurance company and ask to speak with the medical claims section. From there ask them if they do pay for automatic CPAP's. I would try this avenue first, especially when looking at what your DME wants to charge you. Now even if the insurance says no, you may want to talk to your doctor to see if he can "rent" your husband an APAP for a couple of weeks to see how he does. I'm saying this as maybe it will help lower your husbands pressure some. Plus if he is a candidate for an APAP, even paying for it online you are still coming out way ahead. You can get a good APAP for about $700. Much better cost than $2400 for just your share.

Now as to mask leaks, if he doesn't need a full face mask he may want to try nasal pillows. I had a pressure of 16 when I was on CPAP. I had lots of problems with masks, but once I got the Headrest (formerly Aura) nasal pillows by AEIOmed I didn't have any other problems.

Melinda

[Ric]

our DME told us Auto machines are not covered, hence the bi-level.

You should contact the insurance company directly, find out who within the company is the CPAP/APAP/SleepStudy specialist, and find out exactly what they will pay for.

You have just asked the fox guarding the henhouse a detailed question about the quality and availability of the various hens in the henhouse.

It sounds to me like your DME is very skillfully maximizing their profit while bleeding you AND your insurance provider for all they can get. You say they recommended a BIPAP not because you needed a BIPAP, but because of the reimbursement schedule for the CPAP/APAP. I'm not arguing that a BIPAP would not serve the purpose, or that an APAP would be superior to a BIPAP. It just sounds like pure baloney that the insurance will not spring for an APAP, as your DME has told you. Worst case you may have to pay a small extra to get the APAP over a straight CPAP, on the order of $100 to $150 one-time cost, which is less than the monthly co-pay they are demanding for the rental agreement you mentioned.

If calling your insurance seems like too much hassle, I would suggest call the "billmyinsurance" online people (1-800-266-1575). I have not dealt with them directly, but I will guess they have experience dealing with all the right people and can give you a straight answer. They are a sister agency of the cpap.com folks who sponsor this forum. Certainly they understand APAP. The advice and the fees you mentioned from your DME seem OUTRAGEOUS !!!

(grrrrrrrrrrrrrrr......)

[snorzalot]

After two failed compliance attempts on CPAP (once in 1999 and again in early 2006), my doctor prescribed BiPAP technology. My titration study was at 14, 16 and 18 with pretty good results at both 16 and 18, but higher efficiency during sleep at 16 cm H2O. This mornings results for the past 14 days were 7.12 hours of complaince!

Like your husband, I had difficulty with exhale at higher pressure settings, so enter the BiPAP, a two pressure setting, one at inhale (iPAP) and another during exhale (ePAP). My current settings are 16 iPAP and 12 ePAP. That is a significant jump from 17 iPAP to 8 ePAP. What brand of PAP have you been given?

I have a BiPAP Auto w/Bi-Flex from Respironics. It's capable of running in a variety of modes, but my doctor wants straight BiPAP for now. The Bi-Flex setting was a personal choice. Let me explain part of it so it might help you.

If a BiPAP system is in Auto (automated) mode, it has two scales! The first scale is for inhale (iPAP). I suggest you set that scale for a 17 at 14-20. Likewise, I suggest you set the exhale pressure (ePAP), currently 8 at 8-14. The Bi-Flex technology (very similar to CPAP C-Flex technology from Respironics) is a patient desired setting of 0, 1, 2, or 3 for basically how "comfortable" the pressure changes towards the end of an inhale and beginning of an exhale. It's NOT an additional 1, 2 or 3 cm H2O drop, but a "comfort" setting. I have my machine configured at 3 Bi-Flex, but your husbands mileage may vary.

Please read about Bi-Flex here - http://mseries.respironics.com/Technology.asp#BiFlex

You should also note that IF your husband is snoring (and loudly) during PAP treatment, it's NOT working as intended. His pressure likely needs to be HIGHER. A BiPAP system, like one from Respironics has the ability to increase pressure beyond the typical 3-20 cm H2O (centimeters of water) scale. They will climb to 25 cm H2O for difficult to treat OSA cases which your husband may need.

Once my compliance stage ends in 3 or < months, my insurance company along with my 25% contribution will stop renting my machine and buy it out of pocket. My monthly rent is $260ish with me paying < $70 for the Respironics equipment for a comparison for you.

The day I own the machine, it's going into Auto mode with a scale Now for the hard-to-believe part. I am so used to the 16 inhale setting now, that I couldn't imagine going below that. As a matter of fact I feel like I'm suffocating now if it's in ramp mode at 8 on inhale (I never use my ramp now I start out full force). My old setting on CPAP in the past was 8 and 10--that makes me chuckle now In just 14 days, I've come to love my 16 setting and I recall waking up one time all night last night!

I will likely let my scale go from 16 (I love at the low end and don't need to go lower) up to 22 on the higher end just to see if I have apneas that require that setting to stop. I'll be monitoring my own therapy to see how this goes. The exhale pressure I will always keep a little lower. 10 used to feel crazy on CPAP, but I'm tolerating 12 quite nicely now on BiPAP. I'll probably keep it inline with exhale pressure from 12-18 based on the other scale and monitor it through the software to ensure I'm doing well.

One concern I have for your husband snoring loudly with a setting of 17 is that the pressure is too low now and potentially he may be having some central apneas due to the higher pressure setting and probably NOT due to a neurological disorder even though that could be a possibility. I would DEFINITELY get a copy of his last titration study (polysomnogram) from the sleep lab to evaulate these results. If he's having a central apnea or mixed apnea, it could be that a higher pressure setting wouldn't help either. I had a lot of CSA (central sleep apneas) during my first study, but that was due to my body not tolerating the higher pressures. It takes some time for some to get used to the various pressures so be patient and stick with trying!

Now, during this trial and error phase with equipment, is the time to find something that will work for him even if you have to change machines, masks, etc. a lot. Automated PAP technology on a C or BiPAP system is nice, but if you tolerate pressures well all the time with constant pressure they are NOT mandatory. It's nice as you loose/gain weight, have colds, mask leaks, etc. to have an automated system that can help compensate for so many variables without requiring a constant titration study ($2,334 at my lab) each whack!

The next issue on your agenda is going to be a mask. You'll have to pick between nasal pillows, a nasal mask or a full face mask. Mileage and suggestions will vary WIDELY on this forum and any other forum as so much of this is trail and error and finding what works best for you.

I will comment that a nasal mask is harsh at a pressure setting around 16 cm H2O or greater! I think I can do pretty good with a nasal which I'm considering trying, but most sleep labs and DMEs will recommend a full face when you pressure starts growing towards the top end. This way if you mouth breath, the therapy still works pretty well.

I currently have a Fisher and Paykel FlexiFit HC431 Full Face Mask and a ResMed UltraMirage Full Face Mask. If I could laser cut and reassemble the best pieces from each mask, I'd have it made , but for the most part I like them both very well each having it's own perks/disappointments. I'm even switching in and out some nasal pillows, but 3 hours is my limit on that technology even though I wish I could go higher--it's too harsh of a pressure in my nostrils.

Good luck and hopefully some of this advice will help!

[Mrs. Newbie]

1. Hubby is on a PB 425 Bi-Level with the Resmed Mirage FF mask. He was never shown or given any other masks to try?? Is that normal?? We don't have any access to reports etc., at this time...DME has yet to download anything to date. I realize software can be purchased, but since we don't know if he'll stay on this particular machine, we are waiting on that...at this point I'm assuming the DME should be downloading something soon and providing us details...but I'm not sure since he hasn't called or been back in the last week. Is this normal???

2. Our insurance is HMO Blue Cross, so we have NO coverage for going out of network and "bill my insurance" won't work for us. I did call BC, (huge company) and have spoken to a few customer service reps, none of which are overly familiar with CPAPS etc., but they all told me BC covers (within network), the most appropriate yet least expensive machine. I do think the DME was not giving me the real facts on APAP, I belive he simply would be reimbursed at a much lower rate (CPAP rate) and would lose money, but would be reimbursed higher for Bi-Pap. While I'm not 100% sure, I'm thinking this is part of the problem.

3. I did call our PCP's office yesterday and asked if we could have him changed to an Auto, and they were more than happy to try and help, but have not called back as yet...they needed time to pull records, call the DME and consult with our doc and the sleep lab, so I understand that will take a little time.....and to be honest they truly don't have a lot of experience with apnea patients who aren't on Medicare, so they haven't run into this huge billing issue until now -- they were shocked at how expensive this Bi-Level will be. (We live in a fairly small town--The sleep lab is about 30 miles away and our DME is about 40 miles away, nothing is very close to home). We love our PCP and understand he is not a sleep specialist...and he will happily refer us to one, if we'd like to do that. He had sent us to the sleep lab and all the reports were given to him. We thought for now, we simply wanted to get him treated ASAP and would continue to pursue other doc's as needed. He was referred to an ENT (see sleep study) and that appointment is later this month.

4. Regarding the sleep study....below are excerpts of most of the pertinent data regarding his events....he has all types of apnea events including centrals:
----------

Polysomnogram data shows lights out at 10:31PM. During the first two hours the test diagnostics were done. Sleep latency is normal at 5 1/2 minutes. Sleep efficiency is good at 92%. Review of sleep stages distributiuon showed an absence of REM sleep. 6% of the time is spent in Stage I, 80% in Stage II, 13% in Stage III, and 1% in Stage IV.

During this two hour interval there were 83 obstructive apneas, 13 mixed apneas, 10 central apneas and 81 hypopneas seen totalling 186 respiratory events. The overall apnea hypopnea index is markedly elevated at 99.

and more:

Having fulfilled criteria for split night study, CPAP initiation was begun at approximately 12:30 AM. With upward titration of CPAP, there was some normalization of sleep architecture. 15% of the time was ultimately spent in REM and 12% in stage III and 7% in Stage IV.

Some central apneas were seen along with hypopneas though there was overall suppression of respiratory events. Oxygen saturation improved at 95% with only two minutes of data falling below 90% saturation.

Technician noted that high CPAP pressure were needed to suppress respiratory events.

Impressions:
Obstructive sleep apnea syndrome, severe, with good response to nasal CPAP

Recommendations:
Give high pressures needed and snoring would consider ENT evaluation to rule out anatomic or obstructive causes of upper airway compromise.

Current guidelines call for treatment of apnea hypopnea index is greater than 20. Would consider a trial of nasal CPAP at 17 cms of water pressure. Periodic clinical and lab followup should be scheduled both to assure compliance and to check for continued efficany of the apparatus at the set pressure.

Occasionally patient's will do better with an auto adjusting nasal CPAP device if high pressures are needed consistently. If patient a cannot tolerate a preset CPAP, would consider auto CPAP.End of Report
----------

As you can even see from the report it is suggested that an Auto may be more appropriate and I even mentioned this to the DME when I called him, that is when he told me it wasn't covered and went with the Bi-pap.

I should note that my husband is very easy going and never one to complain, which is why I'm here and I'm making all the calls. I asked him again last night if he had called the DME, but he thinks he needs to try the machine longer and doesn't want to "bug" the man. I, on the other hand don't' think this DME is doing well and if I were the patient, I'd be on the phone to him "bugging" him daily, until I had better results....but that's where we are different. I think my husband would give up treatment if he was aware of the potential costs down the road...which I why I haven't given him all those specifics as yet. I'm hoping to get as much info as I can first and then have a lot of data to give him for other options--any option other than giving up treatment....to me it's a matter of life and death and I absolutely want him to continue...

I hope this additional info will help.....I truly appreciate your input very, very much....this forum is wonderful, truly awesome and has educated me so much in this complex illness. Thank you all again. I look forward to more input....

Happy Friday!
Mrs. Newbie

[Wulfman]

Mrs. Newbie,

With regard to your item #2.
Check with your insurance provider and find out whether YOU are considered "in-network". This would allow you to purchase the equipment from CPAP.COM out-of-pocket and then bill your insurance provider and get reimbursed at the in-network rate.
That's what I did. This is no different than purchasing other prescription items or paying medical bills out-of-pocket and then submitting them to your insurance provider for reimbursement.
Many people seem to overlook this option and then get sucked into a situation with a local DME.....then get ripped off in both costs and service.

Best wishes,

Den

[NightHawkeye]

Check with your insurance provider and find out whether YOU are considered "in-network". This would allow you to purchase the equipment from CPAP.COM out-of-pocket and then bill your insurance provider and get reimbursed at the in-network rate.

Take Wulfman's point seriously, Mrs Newbie. I have BC/BS and was told when I called them that they would only reimburse at the out-of-network 60% rate, but I just cashed the check today for 100% reimbursement for what I bought from CPAP.com.

Regards,
Bill

[snorzalot]

I have found living in a small town with VERY limited DME options, that .. and pay close attention here ..

Items the DME doesn't have in stock are MAGICALLY things your insurance doesn't cover

If you compare pricing on CPAP vs. APAP there's not much difference. I could see an insurance company demanding JUSTIFICATION for going to BiPAP equipment as with most DMEs it's 2x as expensive! We are spoiled on here seeing the cpap.com pricing as comparing it to DMEs.

The part of your last post that struck a nerve with me is

Occasionally patient's will do better with an auto adjusting nasal CPAP device if high pressures are needed consistently. If patient a cannot tolerate a preset CPAP, would consider auto CPAP.End of Report

This means your sleep lab is STATING if your husband can NOT tolerate the pressure they are recommending APAP. My guess is that your DME doesn't have APAP in stock and for whatever reason doesn't want to order one. It's easy to put this theory to test...just call your insurance company and ask if they pay or partially pay for DOCTOR prescribed APAP. Most know of CPAP as it's the oldest, but most also tend to cover to some degree the items doctor prescribed. The part that is discouraging to me about the sleep lab report is that it did NOT mention BiPAP which I think is a great option for patients with higher settings like 17 cm H2O that are not tolerating therapy well. I think APAP is much less effective for a patient (now here me out) that has a lot of apneas/events per hour that requires a higher pressure a lot of the time. The GOAL here is to keep that passage way open to prevent the apneas... with that said there's no better way for a non-pressure-tolerator (is that a real word? ) to be complaint then to have a system with a very distinct inhale pressure and a very distinct exhale pressure--of course it's very cool if you can throw APAP like traits and scale the iPAP and ePAP. Nevertheless, BiPAP and I sing its praises because it has saved my life as far as I'm concerned is a great choice for people that can't tolerate the high pressure all the time. I'm disappointed it wasn't listed in the report as an option.

However, I suspect that is what you received from the DME maybe because partly of what I've said about BiPAP but maybe they had that in stock too

I saw a post earlier today that said a DME should have a dozen or so masks for you to try to see what works for you. In my small town, I was lucky to have them hold up a piece of plastic to see what was "ballpark" close and then give me 1 mask to try with not even a hint there were other options available should I struggle with that. My DME actually seemed angry to be bothered with me the first time I worked with one in 1999 and my sleep lab which was an old apartment building at the time and my sleep doctor which traveled once per month from another city to visit, didn't seem to care either, so staying informed about your own therapy and putting your DME and insurance company and doctor to work for you IMHO is YOUR responsibility if you want to get somewhere. I've had fantastic results this time, but I know inside it's primarily from me staying on top of my case and demonstrating high expectations.

Keep working on your husbands therapy and hopefully you'll find a happy medium that will work for him. Masks really do seem to play such an important role with how many hours of compliance you can sneak in each night early on. The good news is that you have the prescription for the PAP, so now you can (according to budget) trial and error a few different mask options based on recommendations and reviews you read online.

This is a great board with a lot of perspectives on what works and what does not which is very helpful.

Thanks!

[RobertinTX]

snorzalot

I have been on CPAP for years and have letely become interested in bi PAP or maybe APAP. Fron reading your prior post it would seem the machine you have is ideal..
I would be interested in what you think about the APAP as compaired to your bi PAP.
You can PM me if you'd rather.
And thanks,
Robert

[DalePike]

I live in a rural area of the southern Oregon Coast. I have been on an automatic machine since Nov. 2005. It is set at 4 - 20. When I received my Rx for a machine, I went to a local Med. Equip. Supply company. They said my Insurance Company was not in their network. I asked how much they woud charge me for a machine with heater. They said a set pressure machine would cost me $2000. I contacted my insurance company and they said I could either deal with their national supplier or purchase a set up myself to be reimbursed @80%. They didn't care what machine I got. I ended purchasing my equipment from CPAP.COM for a total of $900 plus change. I am a happy camper and saved a few hundred dollars.

[Mrs. Newbie]

Thank you all....we will look into all the options you have all mentioned. I hope BC will help us if we go out-of-network, but it is not looking so good at least for now.

We have calls into the DME and our PCP for more assistance, I'm just hoping we get some.

Thanx again.

Mrs. N