Fighting for a better Machine

[EO_123]

that's awesome, thanks pugsy, thank you. Yeah, I'd really like the ability to try a range. When I had my study done, they said my pressure should be 9, but when my DME looked over my results she said it looked like I had more events at 8 and 9 and proposed we start with 7. I'm really looking forward to being able to determine what is really the correct pressure for me. So can I set the machine between 7 and 9? Is that parameter too small?

[Pugsy]

So can I set the machine between 7 and 9? Is that parameter too small?

Yes, you can set it that way if you wish. The minimum pressure is the most critical and where some people get into trouble thinking that the machine will automatically go as high as it needs to. It does take a bit of time as it raises in increments. So it works best if you give it a bit of a head start and not have the minimum at 4 cm..

When I first started therapy the prescribed pressure was cpap 8 cm. I had the APAP so I went with 8 min and 10 max. I very quickly saw that I was spending most of my time at 10 cm. So I opened the range to 12 cm. Still had some clusters so I raised the minimum in increments till I had 10 cm minimum. During this time I also was increasing the max because I was hitting the ceiling occasionally. So I ended up with 10 min and 20 max because sometimes I have some really super strong events that need 18 cm. Doesn't happen often but the machine will go there if it needs to.
Works for me. Pressure changes have never bothered me.

When newbies are starting out on APAP I do think it is probably a good idea to start at the prescribed pressure or use apap in tight range to minic cpap. Gotta start somewhere. Then evaluate the reports and with educated reasoning make adjustments if they seem to be warranted.

The PR S1 also has demos of the Flex settings so you can test them easily to see which you like the best.
I like AFlex the best but others like CFlex or even nothing. I just imagine you will like the machine a lot. It does a great job and I can help you with the software stuff. The clinician manual is in pdf format. Just send me a PM with your private email address and I will send it to you as attachment. We can't do attachments here at the forum.

[DaveLP]

Once you accept the basic machine, it's hard to get the DME or the Doctor (who is sometimes in league with the DME) to prescribe anything different. If I had spent some time here before my sleep test, I would have been much better off.

I was given a machine within 30 minutes after my sleep test was complete. The sleep lab has techs that fit you and assign a machine type before you go home. It was quite an experience before my first cup of coffee!

I kept the Remstar M100 for two years before deciding I was tired of being in the dark about my therapy. I ordered and paid out of pocket for a Devilbiss Intellipap auto after researching price and performance on this and other forums. It's a great machine, but doesn't chart the flow rates, which would be helpful in determining what is happening during hypopneas. My Apneas are near zero, but hypopneas are frequent. Had I realized this, I still would have gone with the Devilbiss for the price, though.

It pays to research and educate yourself prior to accepting a machine from the DME. Once you do, you are locked into a 5 year replacement cycle unless you buy out of pocket. I approached the doctor about an auto machine and his response was that the correct titration pressure was the most important thing. I have found that the auto spends most of its time at my prescribed pressure within .5 cm h2o, so he was accurate in his comment.

[Pugsy]

I approached the doctor about an auto machine and his response was that the correct titration pressure was the most important thing.

They do get it right sometimes. They also don't get it right sometimes. I was prescribed 8 cm. At that pressure I consistently had AHI near 10. Once I move the pressure up to 10 cm I started getting AHI less than 5.
But then I had minimal sleep during the titration study despite being a full night. 156 minutes with only 5 minutes in REM where I am much worse in regards to number and severity of events. It wasn't a big surprise to find out that the titration pressure was off.

If I had not had a full data machine I would never have known that the 8 cm wasn't effective and likely tossed the machine into the closet as I felt awful with 10 AHI.

[archangle]

I went to see my DME today to pick up my "new" machine. Although she was happy to accommodate my request, I was concerned she would still get the wrong machine - and she did - she got me a PR Plus (as opposed to a PR Pro) I actually used CPAP.com to show her that the Plus did not have efficacy data, I think she had prior experience with a pro and assumed they were the same. Anyway - I talked her into geting me A PR with AFlex. At first she told me I wouldn't like auto - but I asked if it could be set to c-flex if I wanted - she told me it could (it sounds right, but can someone confirm?) Anyway, I have to wait another week for the next machine to come in, but hopefully it will be worth the wait.

She sounds pretty clueless. Maybe she's just ignorant, not malicious. Try to educate her.

The Plus only tells you when you start and stop CPAP each night.

A PRS1 Pro records waveforms, tells you how many apneas you have of which type during the night. Your doctor can use software to look at waveforms of each breath sort of like a heart monitor in a hospital. It will tell you if your mask is leaking, how much and when. The doctor can take the card, see how your therapy is going by looking at the events and waveforms. He can then return the card with a new prescription and try a different pressure and look at the results.

The PRS1 Auto does everything the Pro does. It also does auto pressure, but it can be set to do manual, or to do a narrow range of pressure, for instance, 10-12 cmH2O, in case auto gives you problems. If your CPAP isn't working right, you can put the machine on auto and let it find a pressure it likes. Your doctor can then look at the data, evaluate your data at the pressure it chose and then decide what pressure he likes and set a narrow pressure range or even a single pressure.

One valid point about not liking auto is if someone leaves it set with the starting pressure too low. If you leave the starting pressure at 4 like lots of people do, you have to start the night with too little pressure and have breathing problems for a while before you get to a good pressure. Set the lower pressure to a useful level of treatment. For instance, if you think you need 10, don't set the starting pressure below 8. Personally, I set my starting pressure at a level where it stays there most of the night without having to auto up.

The other problem with autopressure is that sometimes, they will "run away" and go to a high pressure. It's not that common, but if it happens, you can set a lower level for the maximum pressure.

I think some people may complain about auto machines because it gave them a higher pressure than the manual CPAP machine did, but they actually needed the higher pressure because their pressure needs vary or the manual setting was too low to start with.

You should print out some PRS1 Pro waveforms and show her what the Pro can do that the Plus can't.

[EO_123]

I just talked to my DME - my new machine is not in yet - she also decided to wait until now (more than a week later) that is was not able to order the PR System 1 AFlex - that the Auto machines require the doctor's prescription to say "Auto" I know this is mostly horse hockey, but do I really need to get the Rx changed to auto? The machine she ordered was the PR ____ Pro, which isn't a bad second choice, but do you think it's worth fighting the additional mile for the auto?

[Slinky]

Does the script actually say A-Flex??? The straight PR CPAPs do NOT have A-Flex. ONLY the APAPs have A-Flex. If the script does say A-Flex you actually have them by the short-hairs.

[EO_123]

The script says CPAP. I called CPAP.com to see if I could find out if the machine I want is coded under E0601 - and it is. According to them - if the script says CPAP - you can have CPAP or APAP. If the script says APAP - you must have APAP. (basically, you can upgrade, but not downgrade) According to my insurance company, they will pay for anything classfied as E0601 - so that's what I'm trying to confirm. Going to call PR when they re open in 30 minutes. Surely they can tell me with some authority how that particular machine is coded. (that said - the folks I talked to at CPAP.com were very helpful)

[Slinky]

An APAP is a CPAP and HCPCS code e0601.

But a straight CPAP can NOT provide A-Flex - or Bi-Flex for that matter, it can only provide C-Flex. An APAP can provide C-Flex or A-Flex. ONLY APAPs can provide A-Flex. If you script designates A-Flex you are to be furnished w/an APAP whether your DME provider likes it or not.

[EO_123]

My Rx Says CPAP +9 with Headed Humidifier

From what I understand, this is enough to code it as E0601. The +9 refers to pressure, but was all know it's ridiculous to think that that can't change. There is also a line about a ResMed Activa Nasal Mask (not what I use, but it covers me getting a mask)

I talked to my DME again and said "good news, the machines are coded the same, you can give me what I want" She said "I know, but my manager won't let me order the better machine" Soooo..... I got the manager's number and left a detailed number with his secretary. I told him that the Rx was fine, the machine I want is covered by my insurance - I verified it with them, and if he can't get me what I want - I'll find a company that will.

That said.. Ummm, what do I do next? Has anyone ever changed DME's? I'm still under 30 days of starting therapy. (3 weeks in) If I need to change, how does that process work? I do have a copy of my Rx and report. My insurance company gave me the full list of DME's that they work with. But who has actually done this? I presume I'd give that brick machine back to them - tell them to quit billing me (I have to rent the machine for x months and then it's mine) and that's it? Or can I expect a bigger headache.

I really like the person I've been dealing with - her husband has Apnea/CPAP and she's anxious to help and thinks all this is BS. But I told her I won't play games with her company, I know what my rights are. Grrrrr

[Janknitz]

No, you don't need your script to say auto, but if you can get your doctor to change the script to an auto script then your problems with the DME will disappear. They MUST fulfill the prescription as written.

Otherwise here's what I suggest:
1. Call around to other DME's that your insurance will cover and find one who will give you a firm committment for an auto machine (make sure it's not the Escape Auto!). You will need to get a copy of your script to the new DME, so get a copy from your doctor.

2. Go back to the first DME and tell them that if they can't give you the auto you want you will be happy to take your business elsewhere. And don't let them play the "we'll order it and it will take a week" game. They are stringing you along to use up your 30 days, and then will refuse to take back your brick because it's now a "used machine". Tell them if they can't produce it right away you'll go to the other DME. They MUST have autos in stock because if they do get a patient for whom the prescription requires an auto they need to fill it right? That "need to order and it will take a week" is baloney. If they are insistent that it will take time to order, you can go to the other DME or get a WRITTEN promise from this DME that they will provide the exact model you are looking for.

The manager's decision to provide an auto or not has NOTHING to do with your needs or desires. It has only to do with the DME's profit margin. It's your choice if you want to give in to that or not. The Pro is an excellent machine too, but less versatile if you are having a problem or gain or lose weight, or have other condition changes that warrant some problem solving or a new titration. If you are truly fine with the Pro vs. the Auto then go for it, but don't let it be the DME's decision. You are going to be stuck with this machine for the next 5 or more years, so it should be YOUR decision alone.

[EO_123]

Thank you Thank you!

I got a list of other DME's and I plan to start contacting them tomorrow. My 30 days will be running out soon - on the 29th - So I really don't have time to play games. What are my rights in terms of returning the machine? Can I pack it up, take it into their business and tell them I'm rejecting it? If I don't have this resolved by the 28/29th is that my best bet - to return the machine so I'm not stuck with a 'used' one? You make a very good point about the auto machines needing to be in stock. I'm a tad furious that my person ordered a different machine and neglected to tell me until today. (stall stall stall)

There is some confusion over who needs to change my prescription - I made an appointment with my primary care doctor - there is a Sleep Dr who did the study, but I've never seen him, he just did the report and wrote the scrpit, but my primary care doctor should be able to rewrite with such a minor change.

[poppi2]

There is some confusion over who needs to change my prescription - I made an appointment with my primary care doctor - there is a Sleep Dr who did the study, but I've never seen him, he just did the report and wrote the scrpit, but my primary care doctor should be able to rewrite with such a minor change.

This link https://www.cpap.com/cpap-faq/Prescriptions.html has CPAP.COM's requirement for a prescription:
-------------------------------------------------------------
"The prescription can be written by any of the following care providers:

Medical Doctor
Doctor of Osteopathy
Psychiatrist
Physicians Assistant
Nurse Practitioners
Dentist
Naturopathic Physicians

We will not accept prescriptions written by:

Chiropractor
Podiatrist
Optometrist
Psychologist

(unless the above is a licensed MD or DO)

snip snip

We have a standard prescription form http://c0149421.cdn.cloudfiles.rackspac ... on-LMN.pdf your doctor can use.

Your prescription can be written on a standard prescription pad which includes the physician's contact information, your name and is signed by the care provider including a statement about the equipment needed. For example:
"CPAP"
"BiPAP"
"CPAP Supplies"
"CPAP Mask"
"CPAP Humidifier"
--------------------------------------------------------------------------------
I printed off CPAP.COM's standard prescription form and had my family doctor sign it.

Good luck, Earl

[archangle]

If the doctor writes "autocpap" and "pressure range x-y" on the prescription, they have to give you an auto.

See if the doctor will help. If the doctor wants "9", write 7-9 or some such narrow range to avoid the problems with badly set up auto machines.

The DME is only doing this to get more money. They can give you any of those machines, but they get paid the same for any of them. Every dollar cheaper goes into their pocket.

Lots of them play this game with requiring auto on the prescription. It's financial policy, not a legal restriction.

If it's midnight and a DME tells you it's dark outside, go look for yourself.

[Janknitz]

Technically, they don't have to take your brick back at all, but if it's a rental you can state that you intend to rent from someone else from now on. Make sure they don't get you to sign anything stating you are refusing TREATMENT. You're not. You're refusing that machine.

Keep a copy of any receipt you get for returning the machine, because the next thing they will do is continue billing you after you return it. Follow up by contacting your insurance company IN WRITING and inform them that you returned the machine to such and such DME on such and such date because you were unhappy with the make and model of machine and that on so and so date you began renting from so and so DME instead.

The clock may or may not run out after 30 days, but the longer you let them string you along the less likely you are going to be able to get this sorted out. So don't delay and don't put up with their stalling.