New CPAP user, a few questions

https://www.cpap.com/plp/apap-machines/ZT0yNzI apap is common term but it just means a single pressure that can auto adjust as needed while in use

https://www.cpap.com/plp/standard-cpap-machines/ZT0yNzE single fixed pressure machines...won't/can't auto adjust at all while in use

The above lists are all going to qualify as E0601 machines for the HCPCS billing code.
E0601 is simply a single pressure (fixed or auto adjusting) machine that provides cpap therapy

Big difference in retail pricing because of features on each machine...some worth it and some just "fluff".
Some provide efficacy data and some don't.
Doesn't matter to Medicare though....they are going to pay the same amount (allowed) for any of those machines.
Same with other insurance companies that pay by the HCPCS billing code.

DME equipment suppliers like to dispense the cheapest model (in terms of wholesale cost to them) that they can that meets the RX requirements. That way they increase their profit margins. DMEs can legally substitute these "cheaper" machines if they have a mind to and the doctor hasn't specified exactly what he/she wants dispensed.
I had this happen with my very first DME and they wanted to provide a non data producing fixed pressure machine that at the time was the cheapest on the market.....I refused it and their services and bought my own machine privately (paid about my 20% co pay for that first machine and it had zero hours on it and it was an apap and full data).
Then I went to another DME and told them I already had a machine and just wanted masks from them and they were happy to do that. So I fired my first DME without ever getting a damn thing from them except the run around.

If a DME has a contract with Medicare or any other insurance company they will have to write off any difference between their pie in the sky billed amount and what gets actually approved/allowed.

Some DMEs will provide what you want simply by your asking for it....but some won't do it.

What I'm not sure about is if that 'feature' is enabled (writing data to the SD card).

It will write to the SD card....the supplier cannot do anything at all to prevent that from happening as long as the SD card is in the slot.
AND...I already provided information on how to get into the clinical menu setup area where you can indeed make any changes you want to change despite them saying you can't. They can't stop you at all and there is no cpap police going around checking. Worse thing to happen...you get your hands slapped and told "don't do that".

Steerpike58 wrote: ↑

Wed Aug 02, 2023 12:29 pm

What I'm not sure about is if that 'feature' is enabled (writing data to the SD card).

There is no enabling. It is enabled as designed by the manufacturer.

Steerpike58 wrote: ↑

Wed Aug 02, 2023 12:29 pm

they won't give me control (I asked, and they said no). Now, it sounds like I could probably figure out how to break in (just use codes from the internet, etc) but ... I'm not sure how the sleep center folks would feel about that so for now, I'm hesitant to do that.

They don't even have to know about it. Just look on youtube to find out how to enable the clinicians menu. If you are so scared, you could disable that menu when you take the machine back.

Steerpike58 wrote: ↑

Wed Aug 02, 2023 12:29 pm

I presume there's no way to recover prior day's information, prior to insertion of the SD card (no internal storage to pull from, etc).

The summary data for prior days will write to the card. For detailed data, which is what you want, the card has to be in the machine throughout the night.

Steerpike58 wrote: ↑

Wed Aug 02, 2023 12:29 pm

Miss Emerita wrote: ↑

Wed Aug 02, 2023 11:23 am

With a little luck, your CAs will diminish now that the EPR is off. Let us know about that, would you?

As others have pointed out, if the CAs persist, it'll be important to understand more about them, and the best way to do that is to use the Oscar software. If you have a laptop or desktop, you're in business. You'll need an SD card in your machine and a way for the computer to read the card. If the computer doesn't have a slot, you can buy an SD card reader for cheap and plug it into a USB port.

Some noses want more humidity, and some want less, so be ready to try out a variety of humidity settings.

I'm a retired IT geek/nerd, so relish the idea of getting reports, etc! I've just been researching OSCAR (Open Source CPAP Analysis Reporter). I see my CPAP machine has an SD card slot and I have SD cards and readers. What I'm not sure about is if that 'feature' is enabled (writing data to the SD card). Currently, the machine is a loaner from Kaiser, and they won't give me control (I asked, and they said no). Now, it sounds like I could probably figure out how to break in (just use codes from the internet, etc) but ... I'm not sure how the sleep center folks would feel about that so for now, I'm hesitant to do that. Regardless, I will plug in an SD card today and see what I find on the card the next day. I presume there's no way to recover prior day's information, prior to insertion of the SD card (no internal storage to pull from, etc).

I see -- you're still using the loaner. So, right, just pop an SD card in there. If the machine is a regular machine, it should write the data onto the card tonight. It won't retrieve data for past nights (as you say, no internal storage beyond a very modest set of data).

I'm a Bay Area Kaiser patient. I suspect every Kaiser facility does things a little differently, but my machine for the first week was a (to me) horrible Philips Respironics machine, and my keeper machine was a ResMed Airsense 10 Autoset, which was *so* much better (for me).

I think the ResMed machines are just better than the PR machines, in addition to the "feel" of the machines. The ResMed algorithms are more nimble and do a better job of heading events off at the pass. They also enable you to see more information in Oscar about flow limitations, and the pressure settings on them can be adjusted in .2 increments, rather than PR's .5.

Bottom line: when it comes time for you to get your keeper machine, I recommend that you make sure it's a ResMed Airsense 10 Autoset or a ResMed Airsense 11 Autoset. And every word counts in those machine names!

Steerpike58 wrote: ↑

Wed Aug 02, 2023 12:45 am

I totally understand that insurance will only pay according to their negotiated 'rates'. What I DON'T understand is, what does the Vender of the DME 'get paid' (and thus what do I actually pay)?

I don't know what the wholesale price is.

What I do know is that mfg's like Resmed tell places like cpap.com what price they will sell their products for AND that they are not to ship out of their usual market.

ie. US sellers cannot ship to CN or GB or AU, etc.

People may not agree but I now wonder IF insurance doesn't keep the prices down is the US because insurance won't pay what some other countries are forced to pay. I know, I know.

HTH

Pugsy wrote: ↑

Wed Aug 02, 2023 12:37 pm

https://www.cpap.com/plp/apap-machines/ZT0yNzI apap is common term but it just means a single pressure that can auto adjust as needed while in use

https://www.cpap.com/plp/standard-cpap-machines/ZT0yNzE single fixed pressure machines...won't/can't auto adjust at all while in use

The above lists are all going to qualify as E0601 machines for the HCPCS billing code.
E0601 is simply a single pressure (fixed or auto adjusting) machine that provides cpap therapy

Big difference in retail pricing because of features on each machine...some worth it and some just "fluff".
Some provide efficacy data and some don't.
Doesn't matter to Medicare though....they are going to pay the same amount (allowed) for any of those machines.
Same with other insurance companies that pay by the HCPCS billing code.

DME equipment suppliers like to dispense the cheapest model (in terms of wholesale cost to them) that they can that meets the RX requirements. That way they increase their profit margins. DMEs can legally substitute these "cheaper" machines if they have a mind to and the doctor hasn't specified exactly what he/she wants dispensed.
I had this happen with my very first DME and they wanted to provide a non data producing fixed pressure machine that at the time was the cheapest on the market.....I refused it and their services and bought my own machine privately (paid about my 20% co pay for that first machine and it had zero hours on it and it was an apap and full data).
Then I went to another DME and told them I already had a machine and just wanted masks from them and they were happy to do that. So I fired my first DME without ever getting a damn thing from them except the run around.

If a DME has a contract with Medicare or any other insurance company they will have to write off any difference between their pie in the sky billed amount and what gets actually approved/allowed.

Some DMEs will provide what you want simply by your asking for it....but some won't do it.

That seems utterly bizarre to me, but - it's the government and I guess I shouldn't try to make sense of it. So - to take a couple of examples from the list you gave, selling at cpap.com:
Resmed Airsense 10 Autoset ... $639 'our price' (cpap.com), $1,199 'list price' (or whatever they want to call it).
Resmed Airsense 11 Autoset ... $989 'our price' (cpap.com), $2,253 'list price'.
That's a huge difference in price between the two models!

They both fulfill the same basic 'function' and are both E0601 'class' machines, and ... Medicare will only pay one number for either machine - 80% of ... some unknown number. A quick google search suggests that the 'unknown number' is around $1,100 - taking this as a source that I could quickly find - https://www.superiorhealthplan.com/news ... rsion.html (it's from 2019, it's specific to Texas, etc etc but - for a ballpark number, is that about right - Medicare considers the '100%' number for E0601 to be around $1,100? So very roughly, if I go through Medicare, some DME vendor somewhere will get 80% of that number from Medicare ($880) and 20% of that number ($220) from me. And that will hold whether I get the Airsense 10 or the Airsense 11. So of course, as you suggest, they will make a lot more profit by selling me the cheaper model. I can imagine that a DME vendor would simply not bother to carry / offer the Airsense 11, because they make so little money from selling it, so the patient loses out due to lack of choice. However - if the numbers above are roughly accurate, even the Airsense 11 is 'only' around $989 from cpap.com, and that includes cpap.com's markup, so even the Airsense 11 still yields a profit if the DME vendor is getting $1,100! So DME vendors seem to be making a killing if they are getting $1,100 for something that cpap.com is selling for $639.

Further - if I decide to go outside my insurance, I could simply go to cpap.com and buy the models at the prices shown on their site.

I guess the ideal outcome would be - I get my Dr to specifically require an Airsense 11, from the DME vendor, and all I have to pay is $220 for something I'd otherwise have to pay around $989 for.

Is all the above roughly correct, in concept?

Pugsy wrote: ↑

Wed Aug 02, 2023 12:37 pm

It will write to the SD card....the supplier cannot do anything at all to prevent that from happening as long as the SD card is in the slot.
AND...I already provided information on how to get into the clinical menu setup area where you can indeed make any changes you want to change despite them saying you can't. They can't stop you at all and there is no cpap police going around checking. Worse thing to happen...you get your hands slapped and told "don't do that".

OMG - just went online and found the 'big secret' (two buttons ... ). I guess I had in mind something more dramatic like the 'rooting' of an iPhone (which can go wrong, and can be irreversible!), or whatever! And once you exit the 'settings' menu, you are back to the same 'basic' mode, so no residual effect. So - piece of cake. I would still want to be 'respectful' of the settings made by the sleep specialist though, as he offered to make adjustments for me. If I show up back at his clinic after a month, and the results are all over the place (and I never called for changes), I would at least want to explain to him what I changed, so the results are in that context. Anyway - SD card inserted and now I actually have something to look forward to tomorrow, to offset the torture of 'the mask'

Miss Emerita wrote: ↑

Wed Aug 02, 2023 3:22 pm

...

I'm a Bay Area Kaiser patient. I suspect every Kaiser facility does things a little differently, but my machine for the first week was a (to me) horrible Philips Respironics machine, and my keeper machine was a ResMed Airsense 10 Autoset, which was *so* much better (for me).
...

I normally use the Kaiser facility in Walnut Creek, but I was sent to the Martinez facility for the sleep stuff. It's further to drive, but - parking has been easy now on 5 visits and the whole place seems very relaxed. I'm new to Kaiser, after decades with John Muir. This is my last year before Medicare, so I figured I'd give Kaiser a try for a lark, since I can switch back easily. Not sure I like it but we shall see ...

MSRP....we all know what that is...listed or advertised price.
online suppliers like cpap.com (who buys wholesale from ResMed direct) have to sign a contract (just to buy wholesale) that the MSRP MUST be shown and sometimes the price is non negotiable. We all know that if cpap.com is discounting from the MSRP that ResMed is okay with it and cpap.com is selling at what ResMed says they can sell it for and yes....we all assume that there is a profit margin even at the discounted prices for those suppliers who purchase directly from ResMed because cpap.com wouldn't inventory an item and sell it at a price where no profit is made. Gotta make a profit to stay in business.

Now DMEs do get to bill out the pie in the sky amount but they write off what they can't get and Medicare (or other insurance) might pay more for a machine than it can be bought on line for but you have to remember some things that we often don't think about.
1....Medicare and often the other insurance will do the 13 month rental...that means the DME/supplier won't have the total funds for over a year. Yet they had to pay whatever entire up front price that they paid wholesale to just get the machine...DMEs didn't get to tell the people they buy from that they will be paid for the machine over the next 13 months
2....DMEs often provide other services that places like cpap.com don't provide. DMEs will bill your insurance for you but cpap.com doesn't. If cpap.com started providing some of those services they would have to hire more people and the end result would be higher prices for everything.

Check with Kaiser as well. They used to have a contract with a supplier and the price to the cpap user was much less than even cpap.com prices. I don't know if your policy will do that or not or even if Kaiser still does that...but check because the price difference was worth it. If you don't ask the answer is always "no".

Steerpike58 wrote: ↑

Wed Aug 02, 2023 7:40 pm

A quick google search suggests that the 'unknown number' is around $1,100 - taking this as a source that I could quickly find - https://www.superiorhealthplan.com/news ... rsion.html

That is not correct. You are looking at the Texas Medicaid fee schedule.

The Medicare schedule for Texas is $839.93 for non-rural, capped 13-month rentals. For rural, it is $1104.61.

Sent Private message

Well, that was an interesting night!

With my new humidifier attachment, and modified settings, I was looking forward to a better night. But it was awful!

To recap - original settings were no humidifier, Ramp on, min 5, max 20, EPR 3. New settings were Humidity 4, Ramp off, min 5, max 15, EPR off.

The humidifier did seem to make the nose dryness situation better; my nose never felt too blocked, or like sandpaper. Progress! But - my mouth became severely dry, to an extent never before experienced in my life! It felt like my teeth were glued to my cheeks, and I was desperate to drink water. Also, air was 'leaking' into my mouth cavity - not through my lips, but (I'm speculating) from my nasal passage - I could feel air being pushed along the inside of my lips, like a bubble moving along. I guessed this may be because the pressure was too high. I suffered in this state from about midnight to 2:30am, and didn't feel like I got any sleep at all (Oscar reported this as a very high API state, over 30 from 1:30am to 2:30am, even though I considered myself to be 'awake'). At 2:30 I gave up and made a change, lowering the max pressure to 10. Situation didn't improve much and I felt like I wasn't getting enough air, and I felt like I still didn't get any sleep through 4:15am. Also, the 'air leaking to mouth' seemed to get worse (Oscar reported a lot of leakage from about 3:45 to 4:15), so I made another change - increasing min pressure to 7, and upping max pressure to 13 (not entirely sure what I was thinking ...). At 5:00am, I was STILL not getting any sleep (my perception), so I turned EPR on (#2 setting) and THAT seemed to make all the difference. Not entirely sure what I was thinking, but I felt like the 'exhale' cycle was really difficult, so I figured EPR may help. So FINALLY - at 5:00am, I feel like I got a half-decent dose of sleep until I woke up at 7:45am and gave up (slept without the CPAP from 7:45am to 10:00am). Oscar reported the AHI at much lower levels for the 5:00 to 7:45 period.

OSCAR certainly gives a lot of data! If someone wants to see a chart, should I upload an image, or is there a way to upload raw data (I presume Imgur is not good for data).

UPDATE - here's my first Oscar screen shot, having followed the steps given in the post that came after mine (looks like I forgot to follow the 'large thumbnail' step; this is created using 'original' but - it seems to fit fine. Let me know if I should re-do it with 'large thumbnail'.).

Note - the 'device settings' on the left only apply to the last 'session', from around 5am to 7:45am.

(an artistic caption for the image - "A lousy night's sleep" )

Steerpike58 wrote: ↑

Thu Aug 03, 2023 12:41 pm

OSCAR certainly gives a lot of data! If someone wants to see a chart, should I upload an image, or is there a way to upload raw data (I presume Imgur is not good for data).

read this here-
viewtopic.php?t=158560

if you have questions, feel free to ask.

good luck!

zonker wrote: ↑

Thu Aug 03, 2023 3:41 pm

....
read this here-
viewtopic.php?t=158560
...

Thanks! I edited my previous post to include the screen shot. Hopefully I got it right!

Steerpike58 wrote: ↑

Thu Aug 03, 2023 5:24 pm

zonker wrote: ↑

Thu Aug 03, 2023 3:41 pm

....
read this here-
viewtopic.php?t=158560
...

Thanks! I edited my previous post to include the screen shot. Hopefully I got it right!

a way for you to ensure you did it right is to hit the "preview" button to check it, then hit "submit".

Steerpike58 wrote: ↑

Thu Aug 03, 2023 12:41 pm

Well, that was an interesting night!

With my new humidifier attachment, and modified settings, I was looking forward to a better night. But it was awful!

To recap - original settings were no humidifier, Ramp on, min 5, max 20, EPR 3. New settings were Humidity 4, Ramp off, min 5, max 15, EPR off.

My comment is not crticising you. But what you just did (instigated by your sleep spcialist...) was changing too many things at once, so now you don't know for sure what made the difference.

But - my mouth became severely dry, to an extent never before experienced in my life! It felt like my teeth were glued to my cheeks, and I was desperate to drink water. Also, air was 'leaking' into my mouth cavity - not through my lips, but (I'm speculating) from my nasal passage - I could feel air being pushed along the inside of my lips, like a bubble moving along.

This type of dryness is a result of of air leaking through your mouth, and into the room. Nasal cavity --> mouth ---> cheeks blowing up ---> lips being pushed open ---> unbleivable, never before experienced desert dryness in mouth.

I guessed this may be because the pressure was too high.

Not necessarily. And "drying mouth leaks" are not necessarily high leaks either.

I suffered in this state from about midnight to 2:30am, and didn't feel like I got any sleep at all (Oscar reported this as a very high API state, over 30 from 1:30am to 2:30am, even though I considered myself to be 'awake').

Anything relating to AHI reported by OSCAR when you're awake is meaningless - wake breathing is irregular, full of interruptions. Sleep Apnea means your breathing is interrupted because you are asleep. The machine doesn't know when you're asleep vs. awake, and records breathing interruptions even when they're not sleep induced. Ignore them.

so I made another change - increasing min pressure to 7, and upping max pressure to 13 (not entirely sure what I was thinking ...). At 5:00am, I was STILL not getting any sleep (my perception), so I turned EPR on (#2 setting) and THAT seemed to make all the difference. Not entirely sure what I was thinking, but I felt like the 'exhale' cycle was really difficult, so I figured EPR may help. So FINALLY - at 5:00am, I feel like I got a half-decent dose of sleep until I woke up at 7:45am

Good thinking. When you focus on the last session, you can see how you have barely any obstructive events reported. But you do have flow limitations - when your pressure is too low. You probably need a higher minimum. However, you're also leaking - so if you make a change in your minimum pressure, make it small, keep all else the same, and keep those settings for next few nights. Focus on getting better control of the leaks. You can check the relationship between leaks, flow limitation and CA's by placing the vertical cursor on the CA's, and looking where it falls in the leak chart and flow limitations chart.

ozij wrote: ↑

Thu Aug 03, 2023 10:23 pm

Steerpike58 wrote: ↑

Thu Aug 03, 2023 12:41 pm

With my new humidifier attachment, and modified settings, I was looking forward to a better night. But it was awful!

To recap - original settings were no humidifier, Ramp on, min 5, max 20, EPR 3. New settings were Humidity 4, Ramp off, min 5, max 15, EPR off.

My comment is not crticising you. But what you just did (instigated by your sleep spcialist...) was changing too many things at once, so now you don't know for sure what made the difference.

But - my mouth became severely dry, to an extent never before experienced in my life! It felt like my teeth were glued to my cheeks, and I was desperate to drink water. Also, air was 'leaking' into my mouth cavity - not through my lips, but (I'm speculating) from my nasal passage - I could feel air being pushed along the inside of my lips, like a bubble moving along.

This type of dryness is a result of of air leaking through your mouth, and into the room. Nasal cavity --> mouth ---> cheeks blowing up ---> lips being pushed open ---> unbleivable, never before experienced desert dryness in mouth.

I guessed this may be because the pressure was too high.

Not necessarily. And "drying mouth leaks" are not necessarily high leaks either.

So no obvious causes for this? Is one remedy to switch to a full-face mask rather than nasal mask? I've been avoiding the full face but if I have to, I'll give it another shot.

ozij wrote: ↑

Thu Aug 03, 2023 10:23 pm

I suffered in this state from about midnight to 2:30am, and didn't feel like I got any sleep at all (Oscar reported this as a very high API state, over 30 from 1:30am to 2:30am, even though I considered myself to be 'awake').

Anything relating to AHI reported by OSCAR when you're awake is meaningless - wake breathing is irregular, full of interruptions. Sleep Apnea means your breathing is interrupted because you are asleep. The machine doesn't know when you're asleep vs. awake, and records breathing interruptions even when they're not sleep induced. Ignore them.

So other than my own perception, there's nothing from Oscar that correlates to actual sleep? In my mind, I was awake for hours and hours that first night, but I imagine there were periods of 'some' sleep in there ... but no obvious way to tell. Last night, my recollection was, I slept pretty much from 2am through 7:30am, with just one interruption for a drink of water. I have Nocturia also (excessive nighttime peeing) but I didn't get up to pee last night till 7:45am).

ozij wrote: ↑

Thu Aug 03, 2023 10:23 pm

so I made another change - increasing min pressure to 7, and upping max pressure to 13 (not entirely sure what I was thinking ...). At 5:00am, I was STILL not getting any sleep (my perception), so I turned EPR on (#2 setting) and THAT seemed to make all the difference. Not entirely sure what I was thinking, but I felt like the 'exhale' cycle was really difficult, so I figured EPR may help. So FINALLY - at 5:00am, I feel like I got a half-decent dose of sleep until I woke up at 7:45am

Good thinking. When you focus on the last session, you can see how you have barely any obstructive events reported. But you do have flow limitations - when your pressure is too low. You probably need a higher minimum. However, you're also leaking - so if you make a change in your minimum pressure, make it small, keep all else the same, and keep those settings for next few nights. Focus on getting better control of the leaks. You can check the relationship between leaks, flow limitation and CA's by placing the vertical cursor on the CA's, and looking where it falls in the leak chart and flow limitations chart.

So, increase min pressure by one unit perhaps?

Here's my chart for last night (2nd night with new settings, 2nd night with OSCAR data):


I went to bed circa 1:30am, and kept the mask on till circa 7:15. I left all the settings as they were at the end of yesterday's session - no ramp, min 7, max 13, EPR 2. I at least felt like I got some sleep!

Oscar breaks the session into two halves, roughly - 2h 34m and 2h 41m; not sure what happened circa 4:30am to cause that (I don't THINK I got up to pee, but I have a vague recollection of pausing the machine for some reason - maybe to drink water?).

Also, don't recall anything about the Large Leak circa 3:20am. I note that the LL corresponds to pressure reaching max. I've no idea what went on towards the end, starting circa 6:45am, with all that abnormal 'Cheyne Stokes Respiration - something I'll need to read up on. My AHI numbers were terrible during that last session - consistently above 40. (should I include the chart for AHI?).

Thanks for your interest!