Medical Justification for APAP

John Galt · Post by **John Galt** » Mon Mar 13, 2006 8:33 am

I have been using a Remstar Plus CPAP for 6 to 8 months. I continue to have a lot of fatigue. I assume that I have problems with leaks or that my pressure setting is incorrect (set at 7). Since I joined this forum, I have learned that it would be to my advantage to have an XPAP that allows me to track my status, and my very basic machine is not capable of this function. I have also learned that an APAP might be beneficial.

My insurer will pay for a new machine if my doctor provides adequate justification that it is medically necessary to have these upgraded functions. My doctor (a Family Practitioner) really knows very little about sleep disorders. Can any of you tell me what "medical justification" I need to get from my doctor to justify moving up to a machine that has Auto Adjusting capabilities and that incorporates smartcard technology.

Thanks for your help.

Wulfman · Post by **Wulfman** » Mon Mar 13, 2006 9:43 am

John,

The first one that comes to my mind is:
Better therapy by being able to monitor nightly results.

Best wishes,

Den

Sounds like you had some nasty storms in your area.

wading thru the muck! · Post by **wading thru the muck!** » Mon Mar 13, 2006 10:47 am

Based on how most insurance companies define "medical necessity," it will be difficult to construct an argument based on your description of your situation. Surprisingly, they are more likely to agree to a re-titration (with the assumption that your pressure is too low) than to pay for an APAP. You might talk to your Doc about just upping your pressure to something like 9-10cm to see if that will help. If inadequate pressure is not the issue, but tolerance of the cpap machine, the fact that you are using a pressure of only 7cm leaves little option for improvement regarding the machine. Does your machine have c-flex? If so, check to see if it is enabled.

In the end, you may have to consider another titration with the focus on determining what might be causing arousals. Lacking that, you may consider looking for a cause other than sleep issues.

John Galt · Post by **John Galt** » Mon Mar 13, 2006 11:18 am

I find it amazing that the insurance company would pay several thousand dollars for a sleep study for re-titration, but they make it so difficult to justify obtaining an APAP machine which could eliminate the need for re-titration.
Any other thoughts out there how to justify the new machine. (My current machine is the most basic model which has no other functions such as cflex).

Thanks.

Ric · Post by **Ric** » Mon Mar 13, 2006 11:36 am

APAP has at least the potential to get rid of those top 10% events without upping the baseline pressure. For some, those "pesky" top 10% represent central apnea/hypopneas, and are not considered worth going after. For others that 10% may represent the worst of the worst, the CPAP pressures are inadequate to deal with the OSA events, and the durations are sufficiently long to cancel out whatever benefit you may be deriving from dealing with the lower pressure events. I am amazed at the reported number of "non-responsive apnea/hypopnea" events the "CPAP-only" crowd reports (and tolerates). 90% is what the typical single-pressure titration curve is looking for. It is easy to characterize the remaining 10% as mere "centrals", or "tossing and turning". But without the data it's only a guess. I can say from my own data that if I had used a CPAP at the 7cm at which I was originally titrated, I would have derived almost no benefit from this, and I would have probably bailed early on. My APAP suggests I am a "true" 9, and without an APAP and the data card reader I could not have known. I probably was a "7" for the couple hours during the sleep study; 7 cm eliminated 90% of the events for that brief interval. The titration curve from the EncorePro suggests that 7 cm would only deal with about 35% of all recorded events. What I have learned since (from my own data and others on this board) is that there is a HUGE variability in the way we sleep and the way a machine must respond to compensate for our variable breathing patterns. APAP will respond accordingly, CPAP can't. APAP is newer technology, and quite simply, better therapy.

Moogy · Post by **Moogy** » Mon Mar 13, 2006 12:10 pm

Some have used the justification that they are losing weight, and therefore their pressure needs will be changing rapidly. I guess you could say the same for GAINING weight, too, but maybe the insurance company would not want to hear that one!

Citing that you have had poor results with a straight CPAP might help, but maybe not until it has been tweaked a few times.

Moogy

wading thru the muck! · Post by **wading thru the muck!** » Mon Mar 13, 2006 12:34 pm

John Galt wrote:I find it amazing that the insurance company would pay several thousand dollars for a sleep study for re-titration, but they make it so difficult to justify obtaining an APAP machine which could eliminate the need for re-titration.
Any other thoughts out there how to justify the new machine. (My current machine is the most basic model which has no other functions such as cflex).

Thanks.

John,

It would have been much easier to get an APAP at the time you got your original machine than it is to get your insurance to pay for another machine now. To get a second machine, you will have to demonstrate that the current machine is not working for you AND that an APAP will work for you. Based on what you have said, this will be a difficult task.

If you truly believe that an APAP will work better and your insurance won't pay, you could always buy one yourself. If you shop online (cpap.com) you will find that they are much less expensive than through a local DME. In some cases people find that the "cash" price online is less than their "out-of-pocket" cost through the insurance/local DME.

You might check to see how frequently your insurance will replace the machine... every five years seems to be what people have encountered. How long have you had your machine?

John Galt · Post by **John Galt** » Mon Mar 13, 2006 1:29 pm

I've only had my CPAP since about last May. Shortly thereafter, I discovered this forum from which I learned that the machine they gave me was declared "obsolete" within a few weeks after I received it. By the time that I discovered this, it was too late to change, so I've tried to work with it. But, I continue to be extremely fatigued. I don't know if it is due to leaks, inadequate pressure, OSAs, Central events, or other. Having discovered that others out there have the benefits of a CPAP that includes software for self-monitoring, I would very much like to move this direction so that I can better monitor and control my own therapy. It only seems right to include APAP potential if I make this change. My insurer will pay for another machine, but only if my physician indicates that it is medically indicated. Seems indicated to me if I remain fatigued, and that's certainly cheaper than a new sleep study, so I am still looking for solid arguments why I should have this made available to me.

The Youngs · Post by **The Youngs** » Mon Mar 13, 2006 1:37 pm

My husband justified getting an APAP by losing 15 pounds. Our doctor told them he needed APAP because he was losing weight - already lost 15 pounds! - and it was cheaper than doing new studies.

Snoredog · Post by **Snoredog** » Mon Mar 13, 2006 1:43 pm

Don't be surprised if after getting an APAP you still fatigued, I got a closet full of machines and still feel that way.

But if you want to justify it with your doctor, complain like heck, complain of aerophagia (breathing air), tell them you sleep on your side, back in all positions. Complain of high pressure waking you up.

Or you can just order the thing from cpap.com using your original prescription, they are good for 2 years, you don't need anything special. It is sometimes just easier to pay for the thing outright then hassle with the doctor and insurance. If you already have a Plus humidifier if you order the Remstar auto w/Cflex you can use the same humidifier. So all you need is the basic machine.

Guest · Post by **Guest** » Mon Mar 13, 2006 2:15 pm

I had the same concern. I was using a very basic cpap that had no other options. I don't really care about the apap function, but very much wanted to be able to monitor my own health. I was unable to find a justification that insurance would accept. As a result, they paid for a new study (cost more than a new machine), but I had to buy a cpap that included monitoring functions. I would like to know what an insurer requires to justify smart card capabilities.

Wulfman · Post by **Wulfman** » Mon Mar 13, 2006 5:06 pm

John,

Along the lines of insurance, depending on your coverage, your deductible, your medical expenses for this year (whether or not you've met your deductible), you MAY be money ahead to purchase out-of-pocket (from CPAP.COM). If your prescription doesn't have an expiration date on it (and you still have it), it will not expire (I checked this with CPAP.COM about a week ago)>

Food for thought.

Den

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