New UARS patient? Standard Sleep Study NORMAL.

[jnk]

Thanks for that chart, Uncle Davey.

(I would call you "Sleepy" but don't want to imply you are one of the Seven Dwarfs--and that would be six letters anyway.)

[robysue]

Medicare is up front about exactly when they will and will not pay for a CPAP trial.

Even more important are the criteria for which they snatch the machine back:

http://www.cms.gov/Outreach-and-Educati ... 905064.pdf

Yes, this is scary, particularly for someone who had a long and difficult adjustment period:

Continuous and Bi-level Positive Airway Pressure
(CPAP/BPAP) Devices:
Complying with Documentation & Coverage Requirements

...

Common PAP Device Errors
...
5. No documentation of the treating physician’s face-to-face re-evaluation, within the first
three months of initiating therapy (but after the 31st day), which documents both improvement
in subjective symptoms of OSA and objective data related to adherence to PAP therapy.
(Emphasis added.)

...

What Do I Need to Know to Prevent Errors?
...
4. Remind the patient that a re-evaluation is required for continuing PAP coverage beyond
the initial 3 months. This re-evaluation must document that the patient is benefiting
from, and adhering to, the PAP therapy as ordered (that is, continued need and
continued use). This requirement may be facilitated by the use of compliance cards/memory
cards in the PAP device. (Emphasis Added)

So if you crash and burn for the first 3-4 months in terms of daytime functioning because you're having a real tough time learning how to sleep with a six foot hose attached to your nose and a machine blowing air down your throat all night, it looks like Medicare can decide to discontinue paying for the PAP even if you are compliant and working hard on making this crazy therapy work and the compliance data looks good.

Sheesh.

[robysue]

But the "standard approach" is rapidly becoming do an HST, then here's a 4/20 APAP and GFL.

And this is just plain sad as well as being all too true.

And if you happen to be an "outlier" who doesn't magically get better in the first few weeks? There's a high risk of simply being fired as a patient for "not getting better fast enough."

[robysue]

Anyway...

Once again I'm surprised at how close I match the descriptors for UARS and how few of the descriptors for OSAHS "fit me." (Of course by know I also know I should not be surprised at this anymore.)

Sludge, just how fuzzy is the line for scoring Rule 4B "Hypopneas with arousal" vs. RERAs when there's no esophageal pressure transducer used? Particularly if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

[jnk]

. . . just how fuzzy . . . if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

Although I can't imply an attorney-client relationship, I still recommend Sludge assert fifth-amendment privilege.

[Setj]

Once again I'm surprised at how close I match the descriptors for UARS and how few of the descriptors for OSAHS "fit me." (Of course by know I also know I should not be surprised at this anymore.)

Sludge, just how fuzzy is the line for scoring Rule 4B "Hypopneas with arousal" vs. RERAs when there's no esophageal pressure transducer used? Particularly if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

Do home tests (HST) detect UARS in a patient that does not have apnea or hypopnea?

[justinjustin]

Once again I'm surprised at how close I match the descriptors for UARS and how few of the descriptors for OSAHS "fit me." (Of course by know I also know I should not be surprised at this anymore.)

Sludge, just how fuzzy is the line for scoring Rule 4B "Hypopneas with arousal" vs. RERAs when there's no esophageal pressure transducer used? Particularly if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

Do home tests (HST) detect UARS in a patient that does not have apnea or hypopnea?

Almost definitely not. It may be possible to detect some flow limitation that suggest UARS, but without a Pes and/or EEG measuring concomitant arousals, HST cannot reliably detect and confirm UARS.

[49er]

Once again I'm surprised at how close I match the descriptors for UARS and how few of the descriptors for OSAHS "fit me." (Of course by know I also know I should not be surprised at this anymore.)

Sludge, just how fuzzy is the line for scoring Rule 4B "Hypopneas with arousal" vs. RERAs when there's no esophageal pressure transducer used? Particularly if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

Do home tests (HST) detect UARS in a patient that does not have apnea or hypopnea?

Almost definitely not. It may be possible to detect some flow limitation that suggest UARS, but without a Pes and/or EEG measuring concomitant arousals, HST cannot reliably detect and confirm UARS.

When I had a HST as a clueless newcomer to the apnea world, I was told that my test could detect UARS. I now realize how impossible that would have been and am shaking my head at what I was led to believe.

49er

[Physician]

I believe that much of Dr. K's genius isn't so much in what he prescribes or how he diagnoses conditions but in how he finds a way to make insurance pay for what he prescribes.

I also believe he and his "people" have a knack for informing some patients about, and getting them excited about, SDB in general and his team's crafted customized approach for those with multiple sleep complications, medical and otherwise, who have failed badly with more standard approaches.

Do I think that sort of thing is necessary for every OSA patient? No. Do I believe he sometimes stumbles onto ways of being extremely helpful to individual patients with nonstandard sleep problems or PAP-therapy complications? Yes.

5K IS a serious hunk of dough,--but hey, if it turns a life around . . .

Just me.

As for UARS, the only reason a lab would have to look for it is if the patient's payers consider that a valid diagnosis for qualifying to try PAP. Otherwise, why look for a condition that will earn the patient the same rights to try a CPAP as a diagnosis of "heebie-jeebies" would? Payers dictate what conditions are looked for, since payers have more control over treatments than doctors do, in this day and age. In my opinion. And I still don't think all payers are on board with the UARS thing, whether docs are or not.

She has used CPAP every night, for whatever the reason, she feels the best she has in a year. Awesome. Yes, to get a CPAP machine and supplies, the DMEP requires a prescription, progress notes, and an abnormal PSG.

[Sludge]

. . . just how fuzzy . . . if it's known the insurance company will pay for treating OSA, but will not pay for treating UARS?

Although I can't imply an attorney-client relationship, I still recommend Sludge assert fifth-amendment privilege.

I hereby invoke my Fifth Amendment right, and insist upon a fair and speedy public trial by jury.

[jnk]

. . . requires a prescription, progress notes, and an abnormal PSG.

But preferably, as a general rule, not in that order, as in:

. . . now got her AHI all the way down to 12.1 from 0.0, . . .

Then again, personally, I care more about subjective results than squigglies. And:

. . . she feels the best she has in a year. . . .

In my opinion, response to therapy is the ultimate diagnostic tool in many instances in which the treatment is harmless to virtually all and is much less costly than the lab work. Why order a CT to see if the aspirin is reducing inflammation? I'll settle for the subjective report from the user instead.

Just me.

If patient is happy, the only thing left is to find a way to do the paperwork to make payers happy. Then the paid can be happy too! I mean, it's not like there is a big problem with recreational use of PAP therapy out there, or anything.

The objective squigglies are there to record and report reality. But the reality is in the improved sleep of the patient, not the accepted objective proof of it that gets submitted to payers. It gets back to the philosophical truism that the picture of a thing is not the thing itself. Even carefully made photographs can be unintentional lies, depending on the framing of the shot. (No insult meant to the photographers.) Much the same way that mathematics is not reality but merely a language for describing and learning about reality.

The PSG is the mathematical snapshot. The sleep is real.

Oops. My soapbox just broke. Think I need to lose weight.

[Sludge]

I mean, it's not like there is a big problem with recreational use of PAP therapy out there...

I'll say.

I mean like, you can't get half the people who are supposed to use it, who need to use it, to comply even 70% of the time, much less people who don't need it in the first place.

[Sludge]

. . . now got her AHI all the way down to 12.1 from 0.0, . . .

Then again, personally, I care more about subjective results than squigglies. And:

. . . she feels the best she has in a year. . . .

In my opinion, response to therapy is the ultimate diagnostic tool.

But "IMHO", an unfounded, anonymous, illogical, anectdotal, syllogistic analysis could just as easily be (more, actually) a cover for some nefarious plot (usually involving money).

[jnk]

As a resident card-carrying conspiracy theorist, I collect nefarious plots. And they always involve money. But to which do you refer?

1. Manufacturers plot to make money by putting an ASV next to every pillow.

2. OSA farms plot to make a buck by testing every human who breathes.

3. Payers plot to save money by disqualifying people who might benefit from PAP.

Until PAP's biggest problem is a combination of being overprescribed and being used by people who don't benefit from it, I'll look the other way on the first two plots and only fight the third.

Compliance should, theoretically at least, prove the diagnosis in itself--since I doubt anyone who was not getting benefit would comply.

But my views tend to be a little warped and outside the mainstream. That's why I'm glad my views are only here among many other views on such matters.

[Physician]

During the past week, here are her average values. Your thoughts (other than leak seems too high) ?

Leak 0.5 L/sec.

AHI 8.5

AI 3.2

HI 5.8

Pressure 12