Change in Governmental Requirements for an APAP in Canada?

[rhowald]

New issue with my DME now.

I had my doctor write a new prescription for an Auto machine, and my DME filled it with a loaner. "We just need to see your pressures to see if you need a BIFLEX machine" is the excuse I was given.

Well now I have had the auto machine for a month and have run the reports through the DME. Sent them in and I get a call stating that the requirements for an APAP have changed with the government. I told her, "but my doctor wrote me a prescription". The District Manager at the DME told me that this is a new governmental regulation in Ontario since June.

Have any of you heard of this?

For the most of the time I am hovering around 15-16. The DME lady told me that my 90% number is 17 and 18 (2 reports to cover the month) so I don't qualify for an auto machine.

I am finally starting to see improvement since I have the auto machine and the reports are showing that my AHI is low. With the straight CPAP at 19 I felt miserable all the time, but had no data to tell me if it was high AHI or what was going on.

I am convinced I need an auto machine and data capability. I told her that if they cannot fill my doctor's prescription to refund me my out of pocket expenses minus the cost for the mask (which was outrageous - 3x what the same mask costs at CPAP.COM) and a reasonable fee for rental of the APAP machine for the two months that I had my plus and APAP.

Anyone have an idea what this should cost in Canadian Dollars (2 months Remstar Auto rental)?

I am so upset right now, I can't even put it into words. I appreciate any input on these issues.

Thanks,
Rob

[Slinky]

Well, is there any way you can double check what the DME told you about the new regulation? Like is there a government website? Or ask the DME to provide the regulation in writing. Does your DOCTOR who wrote the order for the autoPAP have the download information or do you have copies of the download or is the DME the only one who has access to that data?

[rested gal]

For the most of the time I am hovering around 15-16. The DME lady told me that my 90% number is 17 and 18 (2 reports to cover the month) so I don't qualify for an auto machine.

Would be interesting to know what the DME lady thinks the "90%" pressure number means.

If she thinks 17 (and 18 ) is THE pressure the machine used 90% of the time, she'd be wrong.

If she thinks 17 (and 18 ) AND pressures BELOW 17 are what the machine used 90% of the time, she'd be right.

Sounds like they want to see a wider range of pressures being used to "justify" an autopap.

To the bean counters it probably seems that it's no big deal whether a person has 15 or 16 blowing at them with straight cpap, vs 17 or 18. The bean counters would consider those pressures "close" to each other anyway, so why should it matter?

But anyone who has to sleep every night trying to breathe out against pressure and dealing with a mask that gets more apt to leak with every extra cm of pressure, knows.... there's a BIG difference in being able to spend most of the night at 15 vs HAVING TO spend ALL of the night at 18.

Sure, there are people who use straight cpap at 17, 18, or 19 or 20, and have no problem with it. But for many, every iota of pressure relief and comfort they can get does make a difference in how well they can sleep with this kind of treatment blowing at them. Or whether they can even "do this" at all.

We spend one-third of our lives sleeping (or trying to.) I'm all for making "cpap" treatment go as effectively and as comfortably as possible. Even if it means buying one's own machine online, if a person has the financial means.

I think my nice normal blood pressure would skyrocket if I had to deal with using a DME or insurance!

[Bones]

I have no idea what 2 months rental on a machine would be. When I did my apap trial my clinic lent it to me at no cost. The following is from the Ontario Ministry of Health dated July 2007, but only applies if you are applying for the Assistive Devices Program.




ASSISITIVE DEVICES PROGRAM
RESPIRATORY DEVICES 1-13
________________________________________________________________
________________________________________________________________
ONTARIO MINISTRY OF HEALTH AND LONG-TERM CARE July 2007
ASSISITIVE DEVICES PROGRAM
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.
7.3.2 Acceptable Evidence of Medical EligibilityONTARIO MINISTRY OF HEALTH AND LONG-TERM CARE July 2007
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.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, auto, APAP

[rhowald]

Thanks for all the responses. That was exactly what I was looking for Bones.

And RG, I think you be right that she doesn't understand what the 90% pressure means because that is what she jumped straight to when telling me why they couldn't do anything.

Again, thanks all.

RH

[syanne]

Hi Rob,

Last Wednesday ( July18), when I picked my CPAP machine.. I was told the Ontario Assistance would pay $780.. and I would have to pay the difference... which for the most basic set up came to some over $250... I needed more than the basic.. eg C Flex, and humidifier... and a full mask.. so I got what she called the "Silver package".. and paid all the difference in price. Today I mailed all that out to my private health insurance (Sunlife) , and I hope they will pick up 80% of what I paid out. Time will tell what they do with it. It would be very nice to get some of the money back.. but if not that is still o.k., because I am just so amazed at how much this therapy is doing for me. I imagine APAP must be considerably more expensive. No one ever mentioned APAP to me, as an option. If your doctor prescribed the APAP, Ontario wouldn't give you any more.. but hopefully if you have insurance, like Sunlife.. they would go from the prescription.. and pay you back some of what you had to spend.

Sincerely, SyAnne

[rhowald]

Welcome Syanne, glad to see you are embracing your therapy.

Wow they saw me coming... I got the lowest end machine (M series Plus), then they tacked on $200 for a mask that costs 70 something dollars from cpap.com. Not to mention the 'maintenance package' which cost me nearly $300. And let us not forget the tin of wipes (which were worth it so I can't know that too much) and after ADP, I had to swipe $850 or so on my credit card.

My insurance is great - through Manulife. My DME and I called them when I was in the office and my understanding is that they will cover the full amount that is not covered after ADP - after they do an analysis on the estimate (just watch, now that I have said that another wrinkle will work it's way in and I will be posting here in a month or two about how I failed there too).

Problem is that the actual cost of the machines are not that different until you add the DME markup.

$665.00 (for Auto) vs. $445.00 (for Plus)

And that $220.00 buys you Soooooo much more machine.

Granted these are in US dollars, but the exchange rate is so close right now. And my understanding is that since it is medical equipment it is not elligible for taxes or duty.

So I am thinking I skip ADP and my DME (who will have to get their hineys in gear to get any more of my business) and go direct to CPAP.COM, have it shipped, then expense back to my insurer. They save money, I get the machine and everyone is happy right?

If only the world were as sunny as that dream.



RH

[syanne]

Hi Rob.. I just looked at the cpap.com site... yes the prices are much better..my mask was "included" in the package price, but another new one will be in the 350 dollar range. Wondering if there is any problem ( as customs) for us to order from cpap? Also.. I don't think my insurance will cover anything I order without an attached prescription.. so getting something extra will be on my own. I see they have hoses for 10 or 15 dollars... I was told that a new hose would cost 40.. and so it goes.

My credit card got quite a big chunk taken out, too.. even more than yours.. but if some of the money comes back, it won't be too bad.

Will be interested in what you are able to manage with your machine. Hope it works well for you.

Sincerely, SyAnne

[sharon1965]

bones quoted:"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."


ahhhh, this explains my doctor's comment at my latest re-check last week; he told me that because my apneas were consistent throughout the night regardless of position or sleep stage, i wasn't a candidate for apap...DAMN IT! what does the government care? well, of course the $$$$$$ almighty dollar dictates everything...then again, he shouldn't assume, like my dme did, that i would only be interested in equipment that is covered by the ADP and my private insurance...bottom line though was that he wouldn't change my prescription
at least now i know why...thanks for this info
sharon1965

[Snoredog]

I thought I laws were really stupid here, they are even more stupid there.

I would go back to your doctor and have them go to bat for you, I would think even there the doctor could override the DME. I would stress to the doctor that the bipap is to keep you on therapy and they are denying you of the machine needed for doing that.

Can you go out of network and just order your own machine online?

[WillSucceed]

So I am thinking I skip ADP and my DME (who will have to get their hineys in gear to get any more of my business) and go direct to CPAP.COM, have it shipped, then expense back to my insurer. They save money, I get the machine and everyone is happy right?

Don't hold your breath on this. Manulife could opt to disallow your purchase because it was made out-of-country. Even though it ends up costing them less for you to purchase from the US, Manulife may disqualify the purchase. I'd encourage you to talk to them first and get it pre-approved.

Also, give some thought to warrenty claims in the event that you get a bum device. Do you want to be dealing with a US company for warrenty or would you rather go to your local equipment supplier? Like most things purchased in the US, the resellers have access to serial numbers and will know that your device was not purchased in Canada.

Having said all of this, I did manage to get my H2O humidifier paid for by Manulife even though I bought it from a DME in Buffalo. It is not impossible to get the insurance company to pay for stuff bought in the US, just tricky. Good luck with this!!