Is this a prescription or a random number?

rhd · Post by **rhd** » Tue Oct 03, 2006 7:16 am

I'm two weeks removed from my initial sleep study and I think I need to evade my HMO if I want non-fatal treatment. During the study I slept for some portion of the first two hours. The technician said that she trivially diagnosed severe OSA, with nearly constant arousals. (I have no numbers.) She came back with a couple full-face masks, confirming that I do a lot of mouth breathing. We got a mask to fit fairly easily. Over the next two hours I got 40-50 minutes of CPAP-aided sleep, then I refused to wear the mask for the rest of the night. I could deal with lower pressures but the combination of high pressure, PSG leads, and being forced to sleep on my back (which I never do consciously) was too much for me.

At this point she suggested that I may have some claustrophobia issues that I didn't know about -- actually she mentioned this at several points during the night -- and it was my choice to continue with the mask or not. If I continued, she could finish my titration that night. If I didn't, I'd have to come back. As I said, I couldn't do it, so she let me sleep my way for the rest of the night while just getting diagnostics. While getting disconnected she suggested that when I made my next appointment -- there was no doubt in her mind that I would have my OSA diagnosis confirmed and be sent back -- I come in during the day for an acclimatization period with the mask. She said I was going to need a fairly high pressure and she understood that it was a little bit much to deal with all at once. I left believing that the process would be: doctor gets study results in 9 days, schedule office visit to receive second study referral for titration, attend second study, doctor gets those results, doctor prescribes CPAP.

Friday (9 days later, right on time) I got a voice mail from my doctor's office saying my referral was in the mail. When I got my mail last night, I discovered that some steps were missed -- my referral was to Apria with a prescription for CPAP at 11 cm, and a year's supplies! No actual script was included -- they just sent it electronically to Apria.

Is there any way my doctor had enough information to prescribe a setting after only 40-50 minutes on the machine in the lab? And when my tech specifically said she did not complete a titration but just had a general idea that my pressure would be high? That's rhetorical unless someone wants to take his side. My real question is, assuming I can't get a doctor to write me a script to take where I want (e.g. our host) to buy my own APAP, should I even bother calling Apria and getting a CPAP set at 11 or table the idea as too dangerous until I can pay for my own sleep study? Hopefully I can get the script without much trouble, but since I'm in an HMO they may refuse.

snoregirl · Post by **snoregirl** » Tue Oct 03, 2006 7:32 am

Assuming the RT was correct that she was "guessing" at a titration...

My opinion is you need an APAP, either for a couple weeks to get data, or as your normal machine to get a good titration. Could also do with Pro2 or M series Pro but would be more cumbersome and slower.

Second point. You doc needs to give you the prescription and a copy of sleep study.
You have that right.

Most doc's fax to a DME. That is just what they do. You have to ask specifically, or better yet just go to the doc's office and ask the office personnel.

The script that is most likely already written will get you a CPAP machine from your HMO. If you want APAP (from a local DME) you most likely need a script that says APAP.

If you have the financial means (and I suspect you do since you are talking about footing the bill for another sleep study) just get the script for CPAP, and buy an APAP from CPAP.com. CPAP script is all you need for that. Around $700 with heated humidifier plus more for mask. Software for less than $200.

If you decide to go with the CPAP through your hmo make sure it is not a Remstar Plus. This machine doesn't record data and with a questionable titration you need data. Auto is easier to get data quicker, but with the Pro2 or the M series Pro you can do it step by step looking at the data and moving slowly as long as you have the software or someone who can read it.

Get the humidifier (for a local DME should be on the prescription).

Also if you want exhale relief you may want that on the script too.

Talk to your doc about the questionable titration and see if he/she can get the DME to lend you an APAP at the very least. Unless you read the sleep study, you can't know what your doc saw in regards to the titration fiasco. He or she may be reading that you have a titrated level and the doc wasn't there so how would he/she know there was an issue?

bdp522 · Post by **bdp522** » Tue Oct 03, 2006 7:39 am

That sound kind-a-like my titration study. I finally got apap set at 7. After 2 months have already moved to a pressure of 9. DO fight for an apap machine. With apria that won't be easy but keep after them. Call your MD and have him change the order to an apap. Mine finally said he would write all future scripts as patient choice.

Brenda

rhd · Post by **rhd** » Wed Oct 04, 2006 12:32 pm

I got in to see a doctor this morning and got a copy of the study results and a new prescription. I also called Apria but found that they don't have any of my information yet. So I think I'll fax this stuff in to them tomorrow, but also place my own order online. If I like what my insurance can do for me I'll get some spare equipment that way, but I'm just going to get the APAP without fighting over it. I'm not exactly overflowing with means, but yes, I can manage this. I may hold off on the software for a month or two so I can buy a good machine. The data will still be there.

The sleep study was interpreted, not raw data. I had an overall RDI of 51.8 and a supine RDI of 103.5. Limb movement index was 42.8 and an arousal index of 4.0. Arterial oxygen desaturation to 85%. Medium to loud snoring. While on 11 cm: no snoring, no obstructive events, RDI 0.0, oxygen >= 95%. "The patient's tolerance for CPAP was quite suboptimal," as I related in my previous post, but I guess they got enough results in that time to make the recommendation.

My internist said that she (speaking for whichever doctor actually did it) just went with the specialist's interpretation. Whatever the technician said during the study was irrelevant and technicians should be seen and not heard. So I had a tech who didn't think the titration was done but a specialist who reviewed it and said it was. My primary doctors are off the hook for this one, just following:

"The patient should be prescribed with CPAP at 11 cm of water using a mask of choice and heated humidifier. However, if the patient continues to be intolerant of CPAP, we would recommend a CPAP desensitization session and/or repeat polysomnography with CPAP titration."

The hospital was able to tell me that my mask was a Respironics ComfortFull. I thought it worked really well for as long as I was able to tolerate it, so at least I know what interface to get.

I wonder what my 90% level will end up being? I'll share data later if it's interesting. Thanks for the help.