Does actual benefit matter in Medicare CPAP compliance?

Does actual benefit matter in Medicare CPAP compliance?

I'm scheduled for my 61-day review soon, and am concerned that if I am honest that my sleep quality is worse with CPAP than without, Medicare will end my CPAP eligibility because I am not showing improvement.

The actual truth is that my Rx is simply wrong, and merely needs to be adjusted, and I need to try different masks in order to optimize my leak situation, but I know that, in general, Medicare will only pay if improvement is continuing.

In a perfect world, my sleep doctor would work with me to optimize my therapy, but unfortunately mine is more of a "sleep mill", with minimal patient contact. My concern is that this mill is simply going to pass on my "no actual benefit" report to Medicare, and then Medicare will drop me.

I'm considering just lying and reporting progress, to avoid the above problem, and then working on optimizing my therapy later on sometime.

If you start lying now, you're setting yourself up for worse things later - more mix ups, etc. If there is a problem now, work through it with the doctor, techs, etc. but don't lie regardless... there are better ways to address stuff.

Lying is not my first choice, but further research confirms that, without progress, Medicare stops paying, and therefore if you report no progress and your doctor merely reports that to Medicare, you will lose coverage.

Ideally, your doctor would instead adjust pressures, masks, etc., to achieve progress, but "my" doctor doesn't personally have ANY contact with patients, and the sleep center is so dysfunctional that the 2 PA's that actually will talk to you routinely give contradictory answers to questions, and have such a patient backlog they just don't have time to work with patients to optimize their CPAP experience. It's what I would call a "sleep mill", designed to make money by running as many sleep studies as possible.

Previously, I was using a BIPAP machine, and I finally just "illegally" experimented with pressures on my own to optimize, and so I know how to optimize my new ASV machine's pressures, but my sleep doctor won't adjust pressures during the 90 day initial compliance period for some unknown reason, and I don't want to "illegally" change pressures on my own, this time.

Medicare doesn't really care if you are getting "actual benefit". That's not the basis for paying for the machine.

All Medicare cares about is COMPLIANCE. Are you using the machine at least 4 hours a night for at least 30 days in a 90 day period of time? If you're not using the machine, Medicare won't pay.

Medicare should care about actual benefit, but that's not as easily measured as compliance. Some machines don't even record and report AHI, they only report is compliance, because Medicare's requirement is strictly based on compliance. If you are using the machine and not getting benefit, Medicare doesn't care.

And if you choose to change the settings to optimize your own treatment, Medicare doesn't care either--that's not the numbers Medicare pays any attention to. There are no CPAP police, and it's not illegal to adjust your own settings.

If your sleep doctor cares enough to check your settings and efficacy data, then the sleep doctor is paying more attention to you than most bother to do, and perhaps you can enlist that doctor to collaborate WITH you to optimize your treatment. If not, you don't have to ever see that doctor again. You're in charge of your care, not the doctor.

It does look as though Medicare requires the *doctor* to say that PAP therapy is beneficial. That opinion could be based primarily on data like your AHI. Has your AHI improved?

I'd recommend changing your settings on your own -- IF you use Sleep HQ or Oscar to general data from your machine and IF you share the data with knowledgeable people, of whom there are many here.

All I am saying is that there is no law that says that sleep centers have to be logical in their choices, and that if I provide them with a negative subjective sleep report, despite low AHI data, they MIGHT just decide "well, the ASV machine is successful treating his apneas, and yet it isn't helping him sleep, so I guess he is just not a good candidate for any type of CPAP therapy at all" (I've already tried straight CPAP an BIPAP).

That's not the conclusion that I draw, but they might. This sleep center is too busy for details, and also just plain dysfunctional.

And as far as my changing pressures on my own, they take that very seriously...no different than my not following Rx instructions for a drug. What doctor is going to retain a patient who doesn't follow Rx instructions for a drug?

soyjer wrote: ↑

Tue Nov 19, 2024 2:20 pm

All I am saying is that there is no law that says that sleep centers have to be logical in their choices, and that if I provide them with a negative subjective sleep report, despite low AHI data, they MIGHT just decide "well, the ASV machine is successful treating his apneas, and yet it isn't helping him sleep, so I guess he is just not a good candidate for any type of CPAP therapy at all" (I've already tried straight CPAP an BIPAP).

Even if you are not subjectively feeling better, yet, if your apneas are being treated that is proof of improvement. There are many health risks for people who have untreated OSA. When I went for a routine test that I had to be put under for, the anesthesiologist was very clear that there were risks not to be using CPAP...and did not want to be connected with my having a cardiac or other emergency. CPAP also helps treat issues like OSA related nocturia.
There are also many Sleep Disorders that are not Related to Sleep Disordered Breathing.
We are all in the process of trying to figure out how to feel better. You just haven't figured it out yet.

soyjer wrote: ↑

Tue Nov 19, 2024 2:20 pm

That's not the conclusion that I draw, but they might. This sleep center is too busy for details, and also just plain dysfunctional.

And as far as my changing pressures on my own, they take that very seriously...no different than my not following Rx instructions for a drug. What doctor is going to retain a patient who doesn't follow Rx instructions for a drug?

My Sleep doctor has retained me for years and he knows I change my pressure. It is not the same as changing a drug Rx. I keep him updated, discuss it with him and don't do any crazy dial wingin'. It is my health and I need to take charge of it because the company that sold me the machine (sleep centre) hadn't a clue how to help me. I haven't been confronted by the cpap police yet.

I learned and am still learning a lot from the experienced people here.

I totally agree with all of the practical advice here...I just think that y'all are having trouble believing how bad a sleep center can be, and/or how seemingly arbitrary their policies and decisions can be.

If it were up to me...if I didn't NEED them for my insurance to pay...I would have no reason to ever see them again.

I have studied online extensively, and have OSCAR, and frankly, at this point I feel that I am more qualified than my sleep center to optimize my therapy, partly because they just don't have the time, and also I seriously doubt that they look at waveforms at all, other than when the actual doctor...whom I have never met...hopefully looks at them for the one night of the sleep study.

At this point I am almost 60 days into my AirCurve 10 ASVAuto compliance period, and my OSCAR waveforms resemble the seismic activity of Krakatoa, largely because I wake up so often, partly because of air escaping through the center of my right punctal plug.
Despite this, the AirCurve reports AHI of ~5 and ONLY HYPOPNOEAS.

My theory as to what is happening is that my ASVAuto Rx (EPAP=8,15 and PS=5,15) gives far more pressure (with 30, or max AirCurve capability) than needed to treat my central apneas, and I already know that I can sleep much better with BIPAP 10/14, and so what I would LIKE to try is ASV mode EPAP=10 and PS=4,9, or ASVAuto mode EPAP=5,10 and PS=5,10.
Also, I need to experiment with mask types. All this will take time.

They said that they "can't" change pressures from the original Rx until the initial 90 day compliance period has elapsed, so I will just have to wait for that date.

But in the meantime I don't want to risk them dropping me by telling them that my sleep is so awful that now I put my 4+ hours per day on the machine in the afternoon fully awake, and sleep at night totally without the machine. Using a 45 minute ramp time works at night, but only if I reset it every 45 minutes!

I'm going to indicate mild improvement on my subjective written report to them (required), to cover myself, and then mention to the PA that I think the pressure is too high because my mask straps have to be so tight to stop leakage, and because of my punctal plug leakage, and because I think that I will sleep better with lower IPAP pressure.
I think that by doing the above I can indicate the required subjective progress while also receiving lower IPAP pressure...(eventually).

soyjer wrote: ↑

Tue Nov 19, 2024 2:20 pm

All I am saying is that there is no law that says that sleep centers have to be logical in their choices, and that if I provide them with a negative subjective sleep report, despite low AHI data, they MIGHT just decide "well, the ASV machine is successful treating his apneas, and yet it isn't helping him sleep, so I guess he is just not a good candidate for any type of CPAP therapy at all" (I've already tried straight CPAP an BIPAP).

That's not the conclusion that I draw, but they might. This sleep center is too busy for details, and also just plain dysfunctional.

And as far as my changing pressures on my own, they take that very seriously...no different than my not following Rx instructions for a drug. What doctor is going to retain a patient who doesn't follow Rx instructions for a drug?

What you say makes sense from a logical standpoint, but this is what we have observed over years of participation in this forum:

1. Most doctors and clinics look at COMPLIANCE data to determine whether to determine whether the machine is doing it's job. As in "good, good, just keep using the machine." IMHO, that's a "bad clinic"--they don't care about efficacy, only compliance numbers. A "good clinic" is one that might say "this doesn't seem to be working, what is the next step?" And at some point they may reasonably conclude it's not a PAP machine." As far as people report here, that's exceedingly UNCOMMON. In most cases, the PAP is the only tool in toolbox, so to them, if you're using it and meeting the minimal compliance levels (which, in reality, aren't enough to get good treatment), it must be "beneficial". Exceptions are typically ENT surgeons, who will be willing to try some surgical approach, since they have that tool in their toolbox. In general, around here you never see reports of a medical provider saying "the machine isn't helping him sleep, so let's discontinue it." There SHOULD be more who do say that, there aren't--precisely because, as you say, most sleep centers "are too busy for details, and also just plain dysfunctional.

2. There are certain lung conditions that you could harm yourself by making changes to your pressures, but they are rare and generally you know if you have them. Let's take type I diabetes as an analogy. Type 1 diabetics are given a meter or a continuous glucose monitor and taught to adjust their insulin doses according to the data they get from their glucose meters. A mistake there--or a failure to adjust the dosage when indicated--both could be fatal, so they are educated on how to do it correctly. PAP is much less dangerous unless you have a particular condition, and you sound knowledgeable enough to use your own judgment. But going with disrupted sleep for 90 days because the clinic is rigid about adjustments could put you in a dangerous position, just the same as a diabetic being told this is the insulin dose and don't change it no matter what your blood glucose meter says. IMHO, regardless of what Medicare or lazy sleep clinics and lazy sleep doctors think, the goal here is optimal AHI AND adequate restorative sleep, not compliance numbers.

Robot's points are very valid, too.

Well, I tried to reply but apparently my login timed out (?) and it deleted what I wrote.
I do understand about the possible harm of pressure changes and also about possible harm from lack of sleep.
Bottom line for me is that I am just not willing to risk antagonizing my sleep center, because they are the only one within 70 miles, and because they are quite capable of dropping me solely because I antagonize them. They can afford to be that way because they are "the only game in town".

I have no idea who or where my "Sleep Center" or Sleep Doctor" is.
It has been several years since I visited one. The last two I visited I saw a PA. I wouldn't recognize the Doctor if he bit me.
Any actual advice I have received from an SD turned out to be the opposite of what actually worked.
So for at least the past ten years I have done reasonably well with my collaboration with the knowledgeable folks here.
I usually keep my AHI below 1.0 with an occasional Bump to 3 or 4.

My wife started PAP last Christmas. I selected the mask over the objection of the RT. We brought the machine home and I changed the settings before the first use and again after I looked at the first nights Oscar report. Nobody has complained or even noticed any of the changes I have made. Our Medicare Advantage Plan has paid with no hiccups yet. If "Medicare" should complain I will find a "Black Friday" deal or a used Airsense 10 and buy it outright and forget about "Sleep Center" or Sleep Doctor". My wife had her first 0 and she gets 0.1 AHI frequently. She has never seen an actual Sleep Doctor, just an at home test.

A little curious how my doc will react when I see him a couple of weeks for my first 'compliance checkup' ... first followup appt. within 90 days for me. Don't have medicare myself but figure insurance compliance is probably the same.

I expect it'll be pretty much a "How are you doing, blah blah' sort of appt, and he'll then ask the sleep ENT guy to check my data, see if I have been using the thing, and that'll be it.

The doctor who handled my apnea test and confirmed diagnosis is also a doctor I have never actually met. He's not even in the office I go to. Weird setup with an ENT clinic, but my ENT sort of is like a middleman.

I see no harm in saying that you think you have some mild improvement or it's a work in progress ... and would like to followup with some changes to your settings at a later time. Not that I expect anyone to really care what you say, as I assume the data is all they look at. For myself I just plan to tell my doc that I'm working on it, AHIs are better (on my machine anyway), but I may not be sleeping so great ... need more time with it.

Only odd part for the OP may be this bit?

But in the meantime I don't want to risk them dropping me by telling them that my sleep is so awful that now I put my 4+ hours per day on the machine in the afternoon fully awake, and sleep at night totally without the machine. Using a 45 minute ramp time works at night, but only if I reset it every 45 minutes!

Don't think you'd need to tell them this, they can see it on the machine's data? If they care that is. Maybe all they care about is 4hrs of use and the rest doesn't matter.

My new cpap supplier made a big deal of compliance with Medicare, so they would get paid. They would not ship any more supplies. I met with my primary physician shortly after getting my new cpap machine in July 2024, too soon for Medicare compliance. I had to reschedule and get his notes for them "that it was helping", in their words. I said it was better than no cpap therapy which was true. After that I was able to get replacement supplies. Then Medicare audited my supplier, never heard the outcome however.
I have to see how I do after a major neck surgery in Jan 2025. I may look for a bilevel machine if need is indicated.

Anonynose wrote: ↑

Thu Nov 21, 2024 12:04 am

Only odd part for the OP may be this bit?

But in the meantime I don't want to risk them dropping me by telling them that my sleep is so awful that now I put my 4+ hours per day on the machine in the afternoon fully awake, and sleep at night totally without the machine. Using a 45 minute ramp time works at night, but only if I reset it every 45 minutes!

Don't think you'd need to tell them this, they can see it on the machine's data? If they care that is. Maybe all they care about is 4hrs of use and the rest doesn't matter.

For both my Dreamstation ASV sleep study AND during my Resmed ASV 90-day initial compliance period, both machines were set up to allow IPAP up to the full capacity of the machines (~25 cmH20), and I'm thinking this is because they want to maximize the potential for success, but I do wish that they were more sympathetic to the idea that if the machine is hammering me so hard that I can't sleep, then that is NOT success.
Eventually I will get them to lower the max IPAP, but during the sleep study they wouldn't lower it even though I was fully awake for the 1st 4+ hours of the study, and in and out of sleep for the remaining 4 hours, with air blowing out of my right punctal plug the whole time. I kept telling the technician that it's supposed to be a "sleep" study not an "awake" study, but to no avail.
And they flat out said that they would not lower the pressure during the initial 90 day compliance period, so I'm just trying to do the best I can without popping my punctal plug out and without going completely without sleep. Thank God for Ramp Time = 45 minutes.

If your AHI is under 5, Medicare and most insurance will cover the CPAP, whether you're deriving any real benefit or not.

Conversely, if it's 5 or over, you can have a problem even if you're feeling much better than before.

The fact that you keep wanting to reset the ramp tells me that the pressure is too high. I would try to get them to lower it.

I can't tell you to lower it yourself, but they only look at the AHI for compliance, so it won't cause you a problem with the insurance.