Titration Studies, how to know if they are correct?

[cindyh]

I am reposting this info under a different heading because i need help and ended up on a different subject.. thanks

I was just wondering how you read the data on this.. I had 2 titrations and insurance does not want to pay for bi pap so they loaned me the remstar auto cpap.. they said it will give me a 90 percent number to see where i am supposed to be..
My first titration was cpap and level was 16, i could not sleep because i couldnt exhale againt the pressure.. doc ordered bi pap titration.
My bi pap titration levels were determined to be 20/8 Now, they set the remstar auto to start at 8 and i would like to find out what it is getting up to.. I still feel so tired. I just wondered what all i had to have to find out the info stored..
They did tell me that a big part of mine was episodes while on my back during testing and i do not sleep on my back, however during the test i had 137 events per hours on my back, and 4.9 on my side.. lowest oxygen level 68 percent, this is what scares me. I just don't know if i truly need a level of 20, the tech did saw at 18, while on my back, my oxygen was still dropping into the 70's.. so it becomes a question of who to trust the techs or the auto machine, my money is on the paid professionals, but i am curious to hear everyones input on this issue.. thanks, this has been a long process for me and i am still not where i need to be at all.

[Snoredog]

DEFINITIONS:
APNEA = cessation of airflow for 10 seconds or greater.
HYPOPNEA =>50% decrease in airflow for 10 seconds or greater with a decrease in oxygen saturation of >3%.
APNEA/HYPOPNEA INDEX (AHI) = apnea plus (+) HYPOPNEA/hour of sleep.
RESPIRATORY AROUSAL INDEX (RAI) = AHI +snoring related EEG arousals/hour of sleep.
AHI/RAI** Scale =<5 events /hour = (none); 5-15 events/hour = (mild); 15-30 events/hour = (moderate); >30 events/hour = (severe).
Respiratory related sleep fragmentation: Sleep arousals due to respiratory events or snoring.
Desaturation = Drop in O2 oximetry distribution saturation by 3% below average saturation.
SaO2 scale: >89%=(none); 85-89%=(mild);80-84%=(moderate); <80% (severe).
EPWORTH SLEEPINESS SCALE =<10=(does not indicate EDS (Excessive Daytime Somnolence));10-15=(indicates daytime somnolence-not excessive);>16 (indicates EDS).
RESPIRATORY EFFORT RELATED AROUSALS (RERAs)=Sleep Arousals due to respiratory events characterized by pressure flow limitations in the airflow indicator channel without significant O2 desaturations.
StageIII and StageIV are combined and referred to as Deep Sleep.
Sleep Efficiency = Normal is >80%
As established by AASM/ABSM 1999.

Normal Sleep Architecture:
Stage1: 5%
Stage2: 50%
Stage3: 10%
Stage4: 10%
Stage REM: 25%

Stage3&4, REM may decrease as we age.

Typical Stuff seen on a PSG Report:
-----------------------------------------------------------------
Arousal: An interruption of sleep lasting greater than 3 seconds.
BR Arousal index: The number of breathing related arousals(apnea, hypopnea, snoring & RERAs)multiplied by the # hours of sleep.

Bruxism: Grinding of the teeth.
Central apnea: A respiratory episode where there is no airflow and no effort to breathe lasting greater than 10 seconds.

EEG/EOG: Comments about sleep stages, brain waves (EEG), or eye movements (EOG)
EKG/ECG: Comments about heart rate, abnormal heart beats, etc.
EMG: Comments about leg movements and or teeth grinding (bruxism).
Hypopnea: A respiratory episode where there is partial obstruction of the airway lasting greater than 10 seconds. Also called partial apnea or hypo-apnea.
Non-supine: Sleeping in any position other than on the back.
NSR: Normal sinus rhythm.
NPSG: Nocturnal Polysomnogram, or sleep study.
(#)Number of Awakenings: The number of pages scored as wake after sleep onset.
Obstructive apnea: A respiratory episode where there is a complete cessation of airflow lasting greater than 10 seconds.
PLMs: Periodic limb movements.
PLM arousal index: The number of periodic limb movements that cause arousals multiplied by the number of hours of sleep.
PSGT: Polysomnographic technologist.
REM latency: Latency to REM(dreaming) from sleep onset.
RERAs: Respiratory effort related arousals. Episodes that are not apneas or hypopneas, often related to loud snoring, that generally do not cause a decrease in oxygen saturation.
Respiratory: Any specific comments about respiratory events.
RPSGT: Registered polysomnographic technologist.
Sleep efficiency: Total sleep time multiplied by time in bed.
Sleep latency: The first 30 seconds (one `epoch' of recording time) of sleep.
Sleep onset: The first 90 seconds (3 `epochs) of uninterrupted sleep.
Sleep stage shifts: The number of incidents of sleep stage changes.
Snoring intensity: Level of snoring loudness determined by the sleep technologist. Ranging in degrees from mild to very loud snoring.
Spontaneous arousal index: The number of spontaneous arousals (e.g. arousals not related to respiratory events, limb movements, snoring, etc) multiplied by the number of hours of sleep.

Stage 1: The lightest stage of sleep. Transitional stage from wake. top
Stage 1 shifts: The number of times the sleep stage changed to stage 1.
Stage 2: The first true stage of sleep.
Stages 3/4: The deepest, most restorative sleep.
Stage REM: The dreaming stage; Normally occurs every 60-90 minutes.
Supine: Sleeping on back.
Time in bed: The time in the study from `Lights Out' to `Lights On'.
Total arousal index: Total number of all arousals multiplied by the number of hours of sleep.
Total # of PLMs: The number of leg movements in sleep that last greater than 0.5 seconds.
Total sleep time: Total time asleep.
WASO: Wakefulness after sleep onset.
WNL: Within normal limits.

[ozij]

Cindy,
Your question actually should be: If the doctor scripred a bi-pap that lowers exhale pressure significantly, how dare the DME give you an APAP to look for a constant pressure?

Your doc scripted a machine that can give you two kinds of pressure, one when you inhale (20 according to your titration) and one when you exhale (8 according to the bipap titration). And that is what you should be getting. There were good medical reasons for that script: you can't exhale against the higher pressure. The auto will not give yu the needed lower pressure when you exhale.

Tell the DME you insist on getting what the doctor ordered, make him / her sign a statement that he/she refuses to follow the doctor's script and accepts responsibility for what that does to your health.

Call the doc - tell him/her they are being second guessed by DME who won't follow their script - complain about how bad you feel, and don't let go till that DME gives you the machine the doctor ordered!

This is a case where you don't even need the auto's data,because it's looking for contstant pressure, whereas you need bi level.


O.

[cindyh]

Thanks guys, I agree, but they keep saying insurance has not approved bi pap and they are doing me a favor by letting me borrow the auto cpap without billing insurance for it.. its just a machine they keep and apparently decide they can use it to mess with peoples settings.. So, according to them i have to wait and see what insurance does, be miserable and risk dying of lack of oxygen>? I feel very knowledgeable with the terms now.. I am a little confused still of why the first titration for cpap was 16, then for bi pap 20/8, i still dont understand it..

[Snoredog]

[quote="cindyh"]Thanks guys, I agree, but they keep saying insurance has not approved bi pap and they are doing me a favor by letting me borrow the auto cpap without billing insurance for it.. its just a machine they keep and apparently decide they can use it to mess with peoples settings.. So, according to them i have to wait and see what insurance does, be miserable and risk dying of lack of oxygen>? I feel very knowledgeable with the terms now.. I am a little confused still of why the first titration for cpap was 16, then for bi pap 20/8, i still dont understand it..

[goose]

Ask your doctor to write you a letter of medical necessity to send to the insurance company. If you have not talked to the insurance company, do so. the DME could be feeding you a line. Bi-PAP's are not inexpensive machines and DME's don't make the same margin on them as they do on CPAP/APAP....

My DME told me that they wouldn't give me an APAP machine, but after consulting with the doc, she wrote a specific script for a make, model and manufacturer. I have that machine and the DME didn't whine too much about having to give it to me. They did say they wouldn't provide me with a Bi-PAP machine, so I may take that as a challenge. I really don't feel I have a medical reason for Bi-PAP (the APAP machine set in CPAP mode is working very well), but I could probably convince the doc I do.....
I constantly have to remind the DME that I really don't give a royal rat's hind end about their profits -- we're dealing with MY health.....

Ozij is absolutely correct -- stay on their butts, insist on them providing what the doctor has ORDERED and do ask for a letter stating they are refusing treatment and will accept liability based on that decision.....Me thinks you'll get your Bi-PAP!!!!!
But again, talk to the insurance company first and ensure they're the ones refusing coverage and then get the letter of medical necessity from the doc and work from there......If you need it, you should have it!!!!

Good luck!!!!! Let us know how you're doing!!!
cheers
goose

[snoregirl]

The key phrase is "they say the insurance...." Have you talked to the insurance company yourself??

Never believe what the DME tells you about YOUR insurance. That is your relationship between the insurance company and you not the DMEs.

That is your first step. Get the insurance people on the phone, and see if they will back you up with the DME, then maybe you want to change DMEs, find out what other ones your insurance company will cover.

[cindyh]

WHO is they? YES, THEY MEANS THE DME

DME's are notorious for being known as lying cheating slime balls, they have taken that award away from the Used Car salesmen in the checkered suit who is now about 5 tiers higher than them.

You are letting the DME dictate your therapy? I CANT MAKE THEM GIVE ME THE MACHINE, AND I DID TELL MY DOC, HE SAID IT IS RIDICULOUS, BUT THE INSURANCE COMPANY DOES TAKE THEIR TIME.

Have you told your doctor this? What did they say? JUST STATED

WHO is saying your insurance won't pay for the Bipap? DME

The insurance company or the DME loaning you the autopap? DME

I bet it is the DME telling you all this crap, they are the ones telling you your insurance won't pay for the Bipap as opposed to the insurance company saying that themselves. I already told you in the other thread what you need to do, but you don't want to listen you'll just keep asking the same question over and over.

I AM SORRY I HAVE OFFENDED YOU SNOREDOG, I DID NOT MEAN TO, MY POLICY HAS NOTHING WRITTEN ON THE SUBJECT, I CANT MAKE CALLS ON WEEKENDS, I DO NOT FEEL LIKE YOU HAD TO ATTACK ME HERE. I AM JUST TRYING TO UNDERSTAND WHY THEY GOT SUCH DIFFERENT PRESSURES< 16 to 20, that is where I want the info..

Go read your policy, go see your doctor and don't allow the DME to dictate what therapy you receive. But unless you have a major disorder such as heat attack or stroke you have to show where you attempted CPAP (which is what an autopap is) and failed before most insurance will pay for one.

I WAS TOLD THIS AND THEY MADE ME DO 1 WEEK ON CPAP *DOCTOR* WHICH I DID IN JUNE. THEN THE 2nd TITRATION WAS SCHEDULED AND HERE I AM.
_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): auto cpap, bipap, Titration, CPAP, DME[/quote]

[rested gal]

I may be mistaken, but it seems I've read that some insurance companies do require that a person show that they are "intolerant" of CPAP (straight pressure) and absolutely can't use a cpap before the insurance will pay for a bi-level (bipap.)

If that's so, Cindy's DME very likely is trying to do her a favor by giving her an autopap to use long enough to kill two birds with one stone:

1. get more info about what pressure is needed

2. do "time" on a cpap machine (which is what insurance regards an autopap to be...just a "cpap" machine) to prove she can't handle the kind of high pressures she may need, and really must have a bi-level to be able to get treatment at all.

Doesn't sound to me as if the DME is trying to jerk Cindy around. There's no financial reason for the DME to not want to give her a bi-level machine. Insurance does reimburse higher for a "bipap" than it does for a "cpap" (autopaps are included in the "cpap" category.) Autopaps are the same billing code as "cpap", but bi-level (bipap) machines have a different billing code and a higher reimbursement. Sounds to me like it's that particular insurance company trying to keep people on the less expensive "cpap" rather than "bipap."

A letter of medical necessity from the doctor for a bi-level machine might speed the process along some, but I'll bet Cindy's insurance company still requires a certain amount of time (couple of weeks? a month?) spent trying to actually use "cpap" (autopap is cpap) before the insurance company will give in and reimburse for switching her to a bi-level (bipap) machine.

Of course there's always method in the insurance companies' madness. If trying to use cpap is so uncomfortable, maybe the person will just quit...period. Not last it out long enough to qualify for "bipap" or even know that there are machines such as bipaps that can make the exhaling a lot easier.

It would probably suit insurance companies fine if EVERYONE who was prescribed "cpap treatment" dropped out. And suit them even more if the drop-outs dropped dead of a heart attack soon after. Stop having to pay out anything at all.

We could talk 'til we're blue in the face to the insurance companies about the unnecessary millions/billions they'll end up paying out for intensive care, stroke, cardiac surgery, etc. that the OSA/cpap dropouts eventually will cost them. Doesn't matter. The bean counters are busy making the yearly bottom line look good to the stock holders.

Dropping dead will help them do that.

[ozij]

I AM JUST TRYING TO UNDERSTAND WHY THEY GOT SUCH DIFFERENT PRESSURES< 16 to 20, that is where I want the info..

I can think of three possible explanations for that:

1. By the time you went to Bi-pap titration you were more used to mask, machine and titration environment --> slept deeper --> your muscles relaxed more --> you needed more pressure to handle your obstructions.

2. They had to limit your straight pap pressure to something your body could handle when you're exhaling, and 16 was good enough - though higher on inhale would be better

They did tell me that a big part of mine was episodes while on my back during testing and i do not sleep on my back, however during the test i had 137 events per hours on my back, and 4.9 on my side.

3. Pressure needs vary - and you may need higher pressure on some nights, less on others. This is especially pertinent because your OSA is positional -- very different on your back and on your side. Is it possible that during the bi-pap titration you spent more time on your back than you did during the straight pap titration - again causing more serious collapses of you airway than during the first titration?

How much time did you spend on your back during the titrations?
Can you get a pulse oximeter to measure your oxygen levels while you're struggling with the auto at home?

If you get to ask the doctor about those results - please tell us the answer!



O.

[cindyh]

I AM JUST TRYING TO UNDERSTAND WHY THEY GOT SUCH DIFFERENT PRESSURES< 16 to 20, that is where I want the info..

I can think of three possible explanations for that:

1. By the time you went to Bi-pap titration you were more used to mask, machine and titration environment --> slept deeper --> your muscles relaxed more --> you needed more pressure to handle your obstructions.

2. They had to limit your straight pap pressure to something your body could handle when you're exhaling, and 16 was good enough - though higher on inhale would be better

3. Pressure needs vary - and you may need higher pressure on some nights, less on others. This is especially pertinent because your OSA is positional -- very different on your back and on your side. Is it possible that during the bi-pap titration you spent more time on your back than you did during the straight pap titration - again causing more serious collapses of you airway than during the first titration?

How much time did you spend on your back during the titrations?
Can you get a pulse oximeter to measure your oxygen levels while you're struggling with the auto at home?

If you get to ask the doctor about those results - please tell us the answer!




Answers:
1.

They actually had me use a new mask, the optilife when i use the swift at home, understand that and hope it won't affect the numbers.. I asked about it before the titration and was told it wouldnt matter, but I dont see how different masks wouldnt change it slightly or more?

2. You have to be correct here because i now remember the tech saying he wanted to take me to 18 in the original cpap titration but he didn't because of the epap pressure.


3. They did have me stay on my back a little longer because the oxygen was dropping and they said the had to titrate to the worst case scenario, so that was it.. It didnt take nearly as much pressure on my side, which is where i stay at home, so i told them it didnt make sense to put me at such a high pressure when I wouldn't sleep on my back , and my response of course, was they had to because i can roll on my back in my sleep and lose oxygen, which is entirely true..

Thanks to you and Rested Gal, and yes, you have the situation with insurance and DME nailed.. that is exactly whey they let me use the autopap, so i wouldn't be out in the cold without any machine at all.. They are trying, it is not them, its my insurance. They gave me my cpap incredibly fast, but I could not handle the 16 constant pressure.. The auto starts at 8 though and i never know how high it gets, would love to know. thanks

[Snoredog]

IF you can find a copy of your Insurance policy (they are usually found on-line) you'll know in advance what they cover and may not cover, then there is no confusion of what the Insurance will pay for and not pay for. Here is an example insurance policy by Aetna on how they cover Obstructive Sleep Apnea equipment:

http://www.aetna.com/cpb/medical/data/1_99/0004.html

They even list why they don't cover UARS, Pillar and other procedures.
You have to read thru your policy carefully, use a highlighter helps, then you don't really need to contact the insurance or fight with the DME you will KNOW what they will cover and not cover.

For example you don't want to have Aetna and be diagnosed with UARS because the policy says:

Upper airway resistance syndrome (UARS) is characterized by a normal apnea-hypopnea index, but with sleep fragmentation related to subtle airway resistance. Guilleminault and colleagues (1993) considered UARS clinically significant if it entails greater than 10 episodes of EEG arousals per hour of sleep in patients with a documented history of excessive daytime sleepiness. They described UARS as multiple sleep fragmentations resulting from very short alpha EEG arousals, which in turn are related to an increase in resistance to airflow. According to Guilleminault, et al. (1993), the resistance to airflow is subtle enough that it is not detected by routine sleep analysis, but can be detected with esophageal pressure tracings. In addition, UARS may not be associated with snoring, the classic symptom of OSA. However, there is no consensus on the criteria for diagnosis or indications for treatment of UARS. Neither the American Sleep Disorders Association nor any other professional medical organization has issued guidelines for the diagnosis and treatment of UARS.

That last sentence pretty much says they won't pay for UARS if you get that diagnosis.

They have similar statements for Pillar etc.

Then for machine types, they may say:

Aetna considers CPAP for the treatment of members with upper airway resistance syndrome (UARS) experimental and investigational.

BiPAP, DPAP, VPAP, and AutoPAP are considered medically necessary DME for members who are intolerant to CPAP. These alternatives to CPAP may also be considered medically necessary for OSA members with concomitant breathing disorders, which include restrictive thoracic disorders, COPD, and nocturnal hypoventilation. An oral pressure appliance (OPAP) is considered medically necessary DME only on an exception basis for members who are unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia from masks.

That single sentence that says "intolerant to CPAP" means you cannot tolerate CPAP for whatever the reason, so in your case it means if you cannot tolerate the Autopap, then they will pay for the BIPAP. Then above that it says "considered medically necessary", that means your doctor must provide a Letter of Medical Necessity in addition to showing you are intolerant to CPAP.

IT IS NOT that they won't pay for a BIPAP, you have to go through certain hoops and read the details before they will pay for a BIPAP. So all you need to do is:

1. Have difficulty with the Autopap trial (tell your doctor you cannot tolerate it).
2. Your doctor writes a Letter of Medical Necessity for Bipap due to intolerance to CPAP,
3. Shows where you "trialed" a autopap which is CPAP, then if your insurance is like Aetna they will pay for the Bipap.

Most insurance follows the guidelines established by Medicare.

I AM JUST TRYING TO UNDERSTAND WHY THEY GOT SUCH DIFFERENT PRESSURES< 16 to 20, that is where I want the info..

You got different pressures most likely because of the type of events seen, if you had a lot of hypopnea and not that many obstructive they would continue to increase IPAP pressure all the way up to 20 cm. EPAP would be increased as you snored or as apnea was seen. The two different pressures on Bipap address the "events" differently than on single pressure CPAP. The difference is when you exhale, it is much easier to exhale against EPAP=8 than it is at AUTOCPAP=16cm.

That is WHY you got different pressure findings in your titrations. If your "CPAP" pressure was high like 16cm your doctor was perfectly right in having you titrated on "Bipap" where they found 20/8.

That 20/8 finding is a larger than normally seen spread of pressures, as mentioned in the other thread the spread is normally around 4 cm difference to 8 cm with Bilevel therapy. That 20/8 finding on Bipap is equal to 16cm on CPAP. The difference is which offer the best exhale relief, well the 8 cm EPAP will be easier than the 16 cm.

But it all boils down to which one you tolerate better. If you don't tolerate the higher pressure then you don't use the machine, don't use the machine, no therapy.
So what they are trying to determine now is if you can tolerate the Autopap, but it all depends on what kind of range they have it set it to and what your AHI is.

A Bipap machine costs double of what an Autopap costs, check for yourself at cpap.com. If you only need that 16 cm pressure for 2 minutes per night then an autopap may be better if the rest of the night you are at 8.0cm pressure. But what you may run into down the road is aerophagia or swallowing of air due to the pressure, that can cause extreme abdominal pain and you will give up on therapy, the Bipap has been shown to avoid or provide relief for that.

The bottom line is if you cannot tolerate the higher pressure then tell them that, if the autopap runs up to 16cm pressure and is the cause you cannot use it, tell the doctor that, then they will have to fight with insurance to get them to get you a Bipap which may help you tolerate the pressure better.

IF you use the autopap and say it is fine that is what they will give you. Just understand if you accept that machine and modality of therapy you may be stuck with that machine for 5 years before insurance buys you another.

Even if you call insurance directly and talk to them on the phone it may not be gospel because of the circumstances of how they may pay.

[cindyh]

Thank you Snoredog, my policy is not online anymore, that would be too easy for me I will have to call them and get a letter of medical necessity .. I do sleep well with the autopap, but I wonder how much pressure i am getting and if it is actually taking care of the events i am having and keeping my oxygen levels up.. I can get the letter of medical necessity, i am not worried about that. I didnt know about that part. i dont know much about autopap at all, but the beginning pressure is 8 and i have never seen it above 10.5 but i was awake of course if i knew it was taking care of my problem and my o2 levels werent dropping, I would be glad to keep it. I will ask the doc about an o2 sensor for home, I didnt know you could do that either, or they recorded.. that would put an end to this.

But once again, I know the autos are cheaper, but my DME did tell me that they had as much trouble getting them approved as BiPaps.. which makes no sense to me..

[Sleepdeprived]

[quote="cindyh"]Thanks guys, I agree, but they keep saying insurance has not approved bi pap and they are doing me a favor by letting me borrow the auto cpap without billing insurance for it.. its just a machine they keep and apparently decide they can use it to mess with peoples settings.. So, according to them i have to wait and see what insurance does, be miserable and risk dying of lack of oxygen>? I feel very knowledgeable with the terms now.. I am a little confused still of why the first titration for cpap was 16, then for bi pap 20/8, i still dont understand it..

[arthuranxious]

I have AETNA, was not intolerant of CPAP and yet when my doc agreed APAP was a good idea for various reasons, the DME gave me one for keeps! I don't know if they really go by policy, or they say "We are getting $135 a month for the machine, we provide almost no services for taht money, so of course we try to give them a machine that costs us $350 but if we have to give them a machine that costs $475 because they scream and complain ---so be it, we just have to wait a month longer for the insurance company payout to be pure profit!"
That is the reality, most patients need virtually no service from the DME (and a good thing too because the typical DME has several charming receptionists, sundry nincompoop gofers and one well trained pro hiding in the basement if really needed) and the payment from the insurance company uis pure profit after the first few months. It is just that much quicker for the DME corporate owner to buy new Infinitis for the bosses, while the respiratory techs crawl around in their ancient Fords, if patients accept cheapest models