Does actual benefit matter in Medicare CPAP compliance?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
D.H.
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by D.H. » Wed Nov 27, 2024 9:01 pm

bwexler wrote:
Wed Nov 20, 2024 8:37 pm
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.
This "supposedly" doesn't happen in the US.

However, I think it's normal in much of the rest of the world.

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soyjer
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by soyjer » Fri Nov 29, 2024 8:09 pm

D.H. wrote:
Wed Nov 27, 2024 8:58 pm
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.
I'm inclined to agree that they are only monitoring Summary Data, and not even looking at my waveform data, other than for actual sleep study nights.

Common knowledge on this forum, but I just verified by using OSCAR that the AirCurve 10 only internally retains waveform data for the current "day" (12pm yesterday -12pm today), and therefore when my sleep center inserts their SD card to download my data, they are only getting Summary Data (no waveforms). I'm pretty sure that this is true for all Resmed and Philips machines.

If they wanted to, perhaps they could use remote monitoring via cell phone signal to gather the waveform data (?), but I doubt that they do... because if they were doing that then they wouldn't need to insert their SD card into my machine at the beginning of each of my visits to the sleep center.

So they only really have my AHI and leakage info, which doesn't consider how much time I was actually sleeping and how much of my data is from during ramp time.

A strange system... :-)

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robysue1
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by robysue1 » Fri Nov 29, 2024 9:19 pm

soyjer wrote:
Fri Nov 29, 2024 8:09 pm
Common knowledge on this forum, but I just verified by using OSCAR that the AirCurve 10 only internally retains waveform data for the current "day" (12pm yesterday -12pm today), and therefore when my sleep center inserts their SD card to download my data, they are only getting Summary Data (no waveforms). I'm pretty sure that this is true for all Resmed and Philips machines.
This is a bit misleading. First, most sleep doctor's offices will ask you to bring in your SD card with the data on it rather than bringing in the whole machine so that they can insert their SD card into it.

One important reason why they do this is that if you insert an SD card into a machine that has already been written to by a different CPAP machine, you are running the risk of getting garbled data. One of the files a CPAP writes on when a new SD is inserted contains the serial number information for the machine writing the data to that card. Typically the CPAP machine itself will report an "error" if there is data written from a different CPAP machine already present on the SD card and it will refuse to write anything on the card until the card's data is wiped and the card is reformatted. That takes a bit of time---more time than a tech or nurse or PA in a sleep doc's office is going to want to spend watching the dang CPAP machine reformat the card and write its data to the care.

If an SD card is inserted in the machine when you are using it, the detailed flow rate data (along with all the other detailed data) is written directly to the SD card. That data stays on the SD card indefinitely until the SD card is full. This is true for both Resmed and PR machines. So if the SD card is always in the machine, when the data is downloaded from the SD card, all the detailed data from the SD card is available for downloading. And that's another reason that sleep doctor offices and DMEs would prefer to download the data from the SD card that has been inserted the whole time you've been using the machine.

Now, in Oscar, all that data will show up in the daily reports as soon as you finish the download.

In ResScan, the official software for Resmed machines, (as I recall), the person doing the download can choose whether to download the detailed data or not. It used to be the case where only the last 7 days of detailed data would be downloaded in ResScan. (It's been a long time since I've touched ResScan.)

In Encore, the official software for PR machines, the person doing the download can choose whether to download one night of detailed (flow rate) data or whether to just do a standard download.
If they wanted to, perhaps they could use remote monitoring via cell phone signal to gather the waveform data (?), but I doubt that they do... because if they were doing that then they wouldn't need to insert their SD card into my machine at the beginning of each of my visits to the sleep center.
While Resmed offers doctor's offices and DMEs the ability to use their cloud software instead of ResScan, many doctor's offices and dmes have not switched to using the cloud. In some cases, they may be worried about data privacy and the potential for HIPAA violations should the Resmed servers be hacked. It is not clear whether the detailed flow rate data is uploaded to Resmed's cloud; if it is, there is no mention of that in the documentation of the professional AirView cloud software for Resmed CPAP machines.
So they only really have my AHI and leakage info, which doesn't consider how much time I was actually sleeping and how much of my data is from during ramp time.
They have usage data---as in how long the machine was run each night. In general, that's the only data that the health insurance companies care about. In the past, that's the only data that Medicare cared about. If the machine is not being used for at least 4 hours on most nights, then Medicare and insurance don't want to pay for the equipment.

Now, it's true, your sleep doc and DME can't tell from the data how much time you were actually sleeping while the machine was running. The naive assumption is that if the machine is running, you are probably in bed and you are probably trying to get to sleep if you aren't actually asleep.
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ChicagoGranny
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by ChicagoGranny » Sat Nov 30, 2024 1:02 pm

The use of CPAP is covered under Medicare when used in adult patients with OSA. Coverage of CPAP is initially limited to a 12-week period to identify beneficiaries diagnosed with OSA as subsequently described who benefit from CPAP. CPAP is subsequently covered only for those beneficiaries diagnosed with OSA who benefit from CPAP during this 12-week period.
Not that the OP needs permission from anyone here, but I have no problem with the OP lying to prevent the sleep center from ruining his compliance with Medicare. :mrgreen:
"It's not the number of breaths we take, it's the number of moments that take our breath away."

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soyjer
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by soyjer » Mon Dec 02, 2024 8:37 pm

robysue1 wrote:
Fri Nov 29, 2024 9:19 pm
soyjer wrote:
Fri Nov 29, 2024 8:09 pm
...most sleep doctor's offices will ask you to bring in your SD card with the data on it rather than bringing in the whole machine so that they can insert their SD card into it...
...So if the SD card is always in the machine, when the data is downloaded from the SD card, all the detailed data from the SD card is available for downloading. And that's another reason that sleep doctor offices and DMEs would prefer to download the data from the SD card that has been inserted the whole time you've been using the machine...
...One important reason why they do this is that if you insert an SD card into a machine that has already been written to by a different CPAP machine, you are running the risk of getting garbled data. One of the files a CPAP writes on when a new SD is inserted contains the serial number information for the machine writing the data to that card. Typically the CPAP machine itself will report an "error" if there is data written from a different CPAP machine already present on the SD card and it will refuse to write anything on the card until the card's data is wiped and the card is reformatted. That takes a bit of time---more time than a tech or nurse or PA in a sleep doc's office is going to want to spend watching the dang CPAP machine reformat the card and write its data to the care...
...If an SD card is inserted in the machine when you are using it, the detailed flow rate data (along with all the other detailed data) is written directly to the SD card. That data stays on the SD card indefinitely until the SD card is full. This is true for both Resmed and PR machines. So if the SD card is always in the machine, when the data is downloaded from the SD card, all the detailed data from the SD card is available for downloading. And that's another reason that sleep doctor offices and DMEs would prefer to download the data from the SD card that has been inserted the whole time you've been using the machine.
Thanks!...I think you may have just explained what happened last time I brought my machine in for my 60 day evaluation...the "doctor" (PA) asked me why I wasn't compliant (64% = not enough days >4 hrs), and I explained to her that I was ACTUALLY 98% compliant, and all she had to do to see that was to look at the display screen on my DreamStation BiPap S/T.
They had gotten their 64% figure by downloading my data onto THEIR S/D CARD...standard practice with them...the DME supplier that they use does not provide S/D cards, nor does the sleep center ask patients to get one, and I am quite certain that if a patient offered them the patient's S/D card, they would refuse it..that's just how they are.
I had to leave...they were over an hour late for my appt....but I left my machine with them so that they could retry.
They called about 3 hours later, and said that, yes, I was indeed 98% compliant, and that they left their S/D card in the machine LONGER this time, and got the correct data this time that way.
I doubt that they would have actually pulled the card out the first time during the download, and so now based upon your comments about leftover downloads on THEIR S/D cards, I think that either the presence of multiple machines' data on their card caused the problem OR that they simply initially mixed up my card with another patient's.
Neither error would surprise me...it is consistent with pretty much every other interaction that I have had with them.

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soyjer
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Re: Does actual benefit matter in Medicare CPAP compliance?

Post by soyjer » Mon Dec 02, 2024 8:44 pm

ChicagoGranny wrote:
Sat Nov 30, 2024 1:02 pm
The use of CPAP is covered under Medicare when used in adult patients with OSA. Coverage of CPAP is initially limited to a 12-week period to identify beneficiaries diagnosed with OSA as subsequently described who benefit from CPAP. CPAP is subsequently covered only for those beneficiaries diagnosed with OSA who benefit from CPAP during this 12-week period.
Not that the OP needs permission from anyone here, but I have no problem with the OP lying to prevent the sleep center from ruining his compliance with Medicare. :mrgreen:
Yeah...navigating this system is no different than dealing with any other dysfunctional system or machine...it's kind of like running a gauntlet...just figure out how it works, and then do whatever it takes to get to the other side without too much damage...the "other side" being the point in time when they stop paying attention you and then you can focus entirely solely upon optimizing your PAP experience.

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