apap prescription

hi guys--

how does this apap prescription protocol work? when i go to my doc on tuesday, do i ask him for an autopap prescription or a cpap prescription. i know it is possible to get an autopap even if he writes me for a cpap, but i don't want the dme to say no to apap because the prescription says cpap. the doc has to call in the prescription to the BCBC risk utlitization review board or somesuch. i also don't want the risk board to say no to apap if they want cpap. i don't know how this works.

can anyone explain? on BCBS i have an individual HMO policy, not a company one.

thanks.

caroline

I don't have your insurance and can't really give you an answer, but I think there is risk either way.

MY INSURANCE wouldn't even agree to an APAP when the doc wrote the script.

MY DME would never have given me an APAP if the script didn't say so, even then it was a challenge to get.

CPAP script works for APAP at CPAP.com but I would doubt any other DME would give you APAP with a CPAP script. MY DME wouldn't even give me the APAP until the doc put a pressure range on the APAP script. You wouldn't put a range on a CPAP script.

I think you are in the middle of a "who knows what will happen". Especially with the doc having to call in the prescription to that board you mention. You don't say what the function of the board is. Billing-wise the insurance would be unlikely to see the apap vs. cpap due to same code, but if someone is reviewing an APAP prescription, they might ask why you need it. If your doc is willing to support your need of the APAP with the Insurance company then it may be fine.

As I recall, you are currently on CPAP now. So the fact that you have "tried" cpap and now doc is prescribing Apap may work in your favor.

As I said, I don't know your insurance, but I can't see you getting an APAP from a DME without an APAP script. So that may be the answer.

Any one else's opinion who might know this insurance situation?

Having just gotten an APAP through Medicare, I found that they wanted the doctor to indicate APAP and wanted the doctor to indicate a pressure range - I titrated out to 11 in the sleep study, my doc wrote 8-12. Of course, you can change that when you get home, like if your doctor told you to try something else - If the doc had not indicated APAP, then i would have gotten a CPAP and if the doc has not indicated C-Flex, I at least would have gotten a machine with the C-Flex turned off - likely I would not have gotten the feature. Since both APAP and C-Flex were indicated, that means that only a Respironics machine was suitable since other machines that allow pressure relief on exhale that are not officially bi-level do not run in auto mode..

Since C-Flex is officially a comfort thing that is medically required only because it allows compliance in situations where there might otherwise not be compliance, then you are allowed to adjust it yourself, just as you are allowed to adjust your humidifier.

IMHO, get the doctor to write C-Flex and APAP with a range on the prescription. Then you are fighting the DME from Day 1 with them trying to change the doctor's notes and not you asking for something the doctor dudn't ask for.

And, you know what? If you can honestly say, "I'm getting the software and I honestly believe I'm more likely to comply if I can download daily and see how it is helping!" that is a medical reason for getting you the machine that you will use.

i hate to be a techie idiot, but what's the difference between c-flex and apap? c-flex is only for cpap machines, right? so does doc write apap or c-flex? apap and c-flex?

i hope he's going to know what to do. there's no prescription on my sleep study or any piece of paper that i have. there's just a prescription number on a label attached to my machine. maybe i'll have to bring in the machine.

i just feel weird because i hardly know this guy and we've never talked apnea before.

thanks so much.

caroline

If you're buying an autopap (any brand of autopap) with your own money and are ordering it from cpap.com, the Rx needs only the word "CPAP" on it. Doesn't even need anything about the pressure mentioned on the Rx, since all autopaps will already be preset at the factory 4 - 20. All the manuals come with it...user manual AND clinician's setup instructions. The machine itself is the only thing that requires a prescription when buying from cpap.com (and most other online stores.) Accessories like masks, humidifiers, software, etc., don't need an Rx.

However, it's a whole different ballgame if you are trying to buy an autopap from a bricks and mortar DME store. Whether you are going to pay for it yourself, or use your insurance, the local DME will want type of machine and pressure (or pressure range) listed on the Rx. If you want a heated humidifier, better have that mentioned on the Rx. If you want a particular brand of autopap, better have the doctor spell it out the full brand name and model in writing on the Rx. And even then the local DME might try to balk, or substitute, or just plain say, "No."

chdurie2 wrote:i hate to be a techie idiot, but what's the difference between c-flex and apap? c-flex is only for cpap machines, right? so does doc write apap or c-flex? apap and c-flex?

APAP (auto-titrating CPAP machine, "autopap" or "APAP" for short) is a type of machine.

C-Flex is not a machine, or even a type of machine. C-Flex is Respironics' trademark name for a comfort feature that's included on most (not all) Respironics machines. C-Flex drops the pressure somewhat when a person exhales. C-Flex can be found on many of Respironics' straight cpap machines, and on their autopap.

ResMed (another manufacturer) also has an exhalation pressure relief feature called EPR.

Advantage of Respironics' C-flex vs ResMed's EPR:
C-Flex can be used when the Respironics autopap is operating in auto mode. ResMed's EPR can be used ONLY when their machines are operating in straight cpap mode...EPR can't be used in "auto" mode, even if the ResMed autopap machine has EPR listed as one of its features. You have to switch to straight cpap mode to use EPR if you're using a ResMed S8 Vantage autopap.

Advantage of ResMed's EPR vs Respironics' C-Flex:
EPR gives an exact number of cm's of pressure relief - 1, 2, or 3 cm's of drop for exhalation. C-Flex gives a vague drop...noticeable in most cases, but very dependent upon the force of a person's exhalation, so can vary.

After you get an exhalation started, EPR's pressure relief moves down and stays down throughout the ENTIRE exhalation. C-Flex kicks the regular pressure back in before the exhalation is finished. In theory, that sounds like EPR would be more comfortable than C-flex, but having used both....to me, EPR (even set for a 3 cm drop in pressure) feels more difficult to breathe out against at the START of exhaling (when we need pressure relief the most) than C-flex does.

I think that may be because C-flex gives as much drop as it can, at the BEGINNING of the exhalation...when you first START to breathe out. EPR seems to give very little drop when you first start to breathe out and doesn't do its full drop until well into the exhalation. You can hear the motor winding down as you exhale. So...for me, EPR feels very resistant when I first start to breathe out, like no exhalation relief at all, compared to the feel of C-flex's drop at the beginning. Others might experience it quite differently, but I was very disappointed in the lack of "give" at the beginning of exhaling with EPR.

At very high pressures, EPR is going to give the full number of cm's of exhalation relief it is set for. C-Flex may not make much of a dent at all at high pressures, since C-Flex depends on how strongly a person exhales in the first place.

All that's just my personal opinion about C-Flex vs EPR.

The only autopap that offers an exhalation relief feature WHILE OPERATING IN AUTO MODE is the Respironics Auto with C-Flex. Nowadays (I'm editing this in 2008) Respironics has an even more comfortable exhalation relief in the M series REMstar Auto with A-flex. A-flex is fabulously comfortable. A-flex feels like as much exhalation relief and smooth, easy breathing as with a bipap machine...to me.

Everyone's comfort level varies. Some don't like one or the other, or either, type of exhalation pressure drop. Fortunately, any of them (C-Flex or EPR...or A-flex in the M series auto) can be turned off if you don't like it. Your mileage may vary!

I think you are on the right track, trying to get an auto. I love mine.

The popularity of the the auto can be seen on Yahoo Auctions. Currently
there are only 2 APAPs and 19 CPAPs listed, and no RemStar Autos..

After my first 'go-round', 6 years ago, I do not trust my health to either a DME company or my insurance company. Therefore, I buy the stuff I want,
and try to collect later.....

Oh, by the way, listen to RG, she is correct 96% of the time..lol..

oldgearhead wrote:Therefore, I buy the stuff I want, and try to collect later.....

ditto . . .

hi guys, particularly rested gal:

so what is the best autopap machine to get? what should i be asking for? choices?

my insurance only allows the "buy now, try to collect later" on items under $500, and i'm 95% sure that applies no matter where you buy it. on items over $500, they have to approve it with their risk management thing, and they give you a list of dme's.

so i have regular doc appt on tuesday and back up on saturday with sleep doc.

thanks, guys.

caroline

chdurie2 wrote:hi guys, particularly rested gal:

so what is the best autopap machine to get? what should i be asking for? choices?

my insurance only allows the "buy now, try to collect later" on items under $500, and i'm 95% sure that applies no matter where you buy it. on items over $500, they have to approve it with their risk management thing, and they give you a list of dme's.

so i have regular doc appt on tuesday and back up on saturday with sleep doc.

thanks, guys.

caroline

Caroline, I don't have insurance so have never had to take into consideration what "they" would approve/not approve or where they'd let me shop. If there were restrictions, that would probably influence what I asked the doctor for.

As for "best" autopap... it's a matter of what features do you want/need? All of them are "best" in their own way, suiting different people.

I'd shoot first for the one machine that can give two kinds of comfort at the same time, and can use software for detailed data about treatment. A true combo machine that can operate as a bipap giving full exhalation relief AND as an autopap, varying the pressure as needed:
Respironics BiPAP Auto with Bi-flex.

If I couldn't have that machine and wanted an autopap that could give some exhalation pressure relief, and could use good software for detailed treatment info:
Respironics REMstar Auto with C-Flex.

However, if I wanted a small machine (sure nice on the nightstand for full time home use, as well as for travel) I'd go for one of these, depending on what was important to me:

If I wasn't going to ever get software:
ResMed S8 Vantage - you can get readouts of detailed info each morning...your overall AHI, number of apneas, number of hypopneas, pressure used, leak rate, etc. The ResMed machines can also use software, I just don't particularly like their Autoscan software as well as the other manfacturers' software.

If the detailed info provided by software was most important to me:
Puritan Bennett Goodknight 420E autopap (This is the machine I use most of the time.)

Bottom line...the autopap I'd want (edited in 2008):

Respironics REMstar Auto with A-flex M series.

I'd get the Encore Viewer software for it.

The necessary card reader can be found here the cheapest (about $31 including shipping) of any place I've seen the reader:
http://www.two-factor.com/shop/index.php?productID=115


I wouldn't want the integrated M humidifier for it, though. Instead, I'd want a separate Fisher & Paykel HC 150 heated humidifier. It can be used with any brand/model of machine and works great.