Clearway-Central - what is the threshold to move to ASV?

[Chuck Connors]

Curious what the sleep docs and insurance companies use as the threshold in making a decision to move a patient to an ASV machine to treat the Centrals. Any ideas? Thanks. -Chuck-

[avi123]

Check this:

viewtopic/t46681/Insurance-denied-ASV.html

[Chuck Connors]

Thanks for the link avi123. I'd be curious if the criteria has changed since 2009, especially since the medical community knows much more about centrals than they did 3 years ago. -Chuck-

[The Sheikh]

Hi Chuck,

Hope you build a good case and get it, since the sleep study already said it's effective for you.

I'm curious how prominent your centrals are and has CPAP/APAP treatment made them worse compared to the sleep study baseline?

I have severe centrals, almost exclusively, and marvel every night at how my ASV machine paces and encourages my breathing to a regular rhythm. Truly an amazing technology for centrals and Cheyne-Stokes respiration.

Didn't even want to fool with those insurance stuffed shirts and bought the ASV myself. Probably saved months of aggravation.


Tom

[Grand-PAP]

re: viewtopic/t81573/viewtopic.php?f=1&t=75 ... ad#p692914

Hi Chuck,

I don't know if this will help you or not. I wrote the above post back in March 2012. My doc put me on a S9 Elite straight CPAP and it did not addess my CA problems. The thread outline the ordeal I went through to transition to ASV.

I clipped the following from that post. It is regarding Medicare, but it outlines what the Doc was required to document for the transition:

______________________________________________________
As indicated above, my DME totally misinformed me regarding the Medicare requirement. In order to qualify for this transition from straight CPAP my doc only had to answer YES to these specific Yes/No questions:

RAD Qualifications: (for BiPAP autoSV mode)

1. Has patient failed CPAP therapy?
2. Is AHI > 5?
3. Is % of central apneas > 50% of total?
4. Are central apneas / hypopneas >= 5/ hour?
5. Diagnosis of CSA or CompSA?

So, even though I am still within the 13 month “lease” period for the S9 Elite, I am able to transition to the ASV therapy.
______________________________________________________

Hope your journey isn't as ROCKY as mine!

[jnk]

An example of how some forms of insurance see it with certain forms of central apnea:

Central Sleep Apnea: Central sleep apnea may be treated with CPAP, bilevel PAP, or bilevel PAP with a back-up rate or servocontroller features. Prior to initiating therapy, complete facility based attended polysomnography must be performed documenting the primary diagnosis of central sleep apnea (CSA).

If central sleep apnea requires pressure therapy and is not adequately controlled with CPAP or standard bilevel PAP, then bilevel PAP with a back-up rate or a servocontroller feature will be covered upon a demonstration of effectiveness.

http://www.bcbsnc.com/assets/services/p ... evices.pdf

The following seems to be an approach suggested by William J. DePaso, MD, of the Virginia Mason Sleep Disorders Center. Don't know if it is good or bad, but it appears to be the approach he suggests in presentations to other docs:

. . . • Send patients home on CPAP or auto
• One month for CSR, longer for CompSA
• If they tolerate and still have CSA on downloads, re-titrate in lab
• If still have CSA bring back for them ASV titration

http://action.lung.org/site/DocServer/D ... d9.app306b

My understanding, therefore, is that lab involvement is necessary BOTH to prove the diagnosis of CSA (including complex) AND to prove the effectiveness of ASV in treating it, if staying within the lines of insurance coverage in many cases. Home-machine downloads are not used to prove CSA or to prove effective treatment for it, to the best of my knowledge, but can, as mentioned above, be used as a clue to indicate the need for further lab investigation and titration.

I ain't no pro, though, and have never used an ASV of any sort, so I may misunderstand all the above for all I know.

[Chuck Connors]

Based on the information you provided, it looks like I qualify. One of the 1st calls that I make this Tuesday morning will be to my sleep doc's office to make another appointment. Thank you. -Chuck-
____________________________________________________________________________________________

re: viewtopic/t81573/viewtopic.php?f=1&t=75 ... ad#p692914

Hi Chuck,

I don't know if this will help you or not. I wrote the above post back in March 2012. My doc put me on a S9 Elite straight CPAP and it did not addess my CA problems. The thread outline the ordeal I went through to transition to ASV.

I clipped the following from that post. It is regarding Medicare, but it outlines what the Doc was required to document for the transition:

______________________________________________________
As indicated above, my DME totally misinformed me regarding the Medicare requirement. In order to qualify for this transition from straight CPAP my doc only had to answer YES to these specific Yes/No questions:

RAD Qualifications: (for BiPAP autoSV mode)

1. Has patient failed CPAP therapy?
2. Is AHI > 5?
3. Is % of central apneas > 50% of total?
4. Are central apneas / hypopneas >= 5/ hour?
5. Diagnosis of CSA or CompSA?

So, even though I am still within the 13 month “lease” period for the S9 Elite, I am able to transition to the ASV therapy.
______________________________________________________

Hope your journey isn't as ROCKY as mine!

[krb39]

I think this thread applies to me. If so, I am in debt to Chuck and to grandPAP for their comments. Some of what I will say is from a less detailed thread i started when I knew less.

Here is the info from above:

As indicated above, my DME totally misinformed me regarding the Medicare requirement. In order to qualify for this transition from straight CPAP my doc only had to answer YES to these specific Yes/No questions:

RAD Qualifications: (for BiPAP autoSV mode)

1. Has patient failed CPAP therapy?
2. Is AHI > 5?
3. Is % of central apneas > 50% of total?
4. Are central apneas / hypopneas >= 5/ hour?
5. Diagnosis of CSA or CompSA?

Here is my situation:


I had an AHI of 50+, CPAP brings it down to 8, with variations as high as 13, and with a mix of centrals and obstructives, centrals more than 50%.

My doc said I should come in to the sleep lab and they would set me up with an auto SV. I arrived and the tech said the order was to start with the S/T and we would go to the auto SV only if I did not handle the S/T well. The S/T is BPAP, but without the automatice pressure adjustment. I did fine on the S/T, but the needed pressure is something like 19/15. This is what they will prescribe for me then, an S/T with 10/15. I called in to ask the doc what happened that I never got to the autoSV he had mentioned. He is gone until mid Lanuary but a staffer said it was because of Medicare regs. I have found no such Medicare regs. I am guessing that when auto SV first came out there may have been some such regs because of the newness, but I do not see that this is the case now.


I want to be a s prepared as possible when I discuss this with them Perhaps what they are doing is exactly right, but it doesn't sound right. Also, the post above from grandPAP seems to me to say that it isn't right.

I want to be accurate, I don't want to go in and raise a fuss about nothing, but I am getting the idea that my treatment is off the tracks a bit. So:

Chuck: Sound right to you that I qualify for ASV, as near as you can understand it? You mention that you were going in to see them. How did it all work out?

[Grand-PAP]

Hi krb39,

If you read through my posts, you got some feeling for the frustration I had trying to force the system to move! Also, if you have read through many other cpaptalk posts, you can see that we get conflicting information from our DMEs, Medicare, Insurance Providers and Doctors. That is compounded by potential variances among different states. And finally, the procedures may have changed since I went through the journey. However . . .

Below I've attached a screenprint I did from my ASV Prescription that was written in March 2012.

Procedurally, I had three sleep studies, a "regular" (whatever that means) to determine I had OSA, a second one for CPAP titration, and then finally the third was for the ASV.

Many posters have written that "to qualify" for ASV, a person must "fail" on CPAP, then "fail" on BiPAP, before being eligible for ASV consideration. I neither had a BiPAP sleep study nor a trial use of a BiPAP.

Others have posted the same "requirement" that you did -- An S/T "failure" is required. I did not have a S/T sleep study and never used a S/T machine.

So, it's difficult to know what REALLY is required. You indicated that your tech said the order was for a S/T. That might be the doctor's requirement and not the Insurance Company or Medicare.

Finally, there have been cpaptalk threads regarding S/Ts, with mixed opinions regarding whether they were effective for CAs. Personally, I am unfamiliar with the S/T and don't have an opinion, but I know that an ASV is effective. Interestingly, the S/T is comparably priced with an ASV and on some sites I have seen the S/T even more expensive than the ASV.

You indicated, "I want to be as prepared as possible when I discuss this." Well, it appears that you are doing that. My personal recommendation would be to press you doctor for a SPECIFIC answer regarding who is "requiring" the S/T. Then I would be as "calm and cooperative" as possible, but I would insist on the ASV.

By the way, if you haven't already gotten a COMPLETE copy of all your sleep studies, I would suggest that you do so prior to your next appointment. Then if the discussion doesn't got as you would like, consider suggesting that you take the studies to another doc for a second opinion.

[krb39]

This is very helpful. I have the results from the sleep study, I believe they are the full version, it is something that I can ask. Since I posted, my wife Becky tracked down some material related to this. It is for a contractor, but it directly addresses Medicare regs. It requires some care in reading it to put it mildly, but with patience I think I can handle it. Of particular interest: It takes effect after Jan 1, 2013.

http://www.medicarenhic.com/dme/medical ... 011-02.pdf