APAPs -- are they becoming standard prescriptions from Docs?

well they are said to be more advanced as they give a automatic variation in pressure which occurs during the night i am using an resmed apap but cpap are found to be more precise so nothing to worry much about it cpap is good enough.

An interesting chart from cpap.com:

https://www.cpap.com/brandChartLines.ph ... machine-vs

Greatuncle Bill said:

insurance companies may have diagnostic criteria that need to be met before they pay for apap.

In reality, it is very rare for an insurance company to care whether you get a CPAP or an APAP, since they are both the same billing code and the insurance company will not pay a penny more for an APAP than they do for a CPAP.

My insurer (Kaiser) is the only one I've heard of so far that reimburses differently depending on whether or not its an APAP.

Sloop wrote:As I don't have one, I am curious as to how often they are prescribed? Seems like an awful lot of folks here have the APAPs. So -- for someone who has regular ole OSA (if you can define "regular"), are APAP prescriptions becoming the norm?

I need a higher pressure in REM, so an APAP is good for me. Maybe I am in REM a maximum of 45 to 90 minutes per night. All the rest of the night I can use a lower pressure which is nice.

I read here that typically more pressure is needed in REM.

My doc wouldn't do an apap, but did let me go for the elite. I got the feeling he wasn't very familiar with the machines themselves. And the tech that gave me the machine either didn't know how to set the machine up or didn't want me to have access to anything because when I asked about seeing the summary data every morning he said the machine wouldn't do that and only they could read the data. I didn't argue with him and just set it up how I wanted it when I got home.

Slinky wrote:

... costs more to make a ResMed s9 Escape than an S9 Auto because of the volumes sold and the extra engineering time to dumb down the product. ...

Say WHAT??? Volume sold??? A LOT more Escapes are sold than AutoSets. A LOT more!!!! The VAST MAJORITY of CPAP patients haven't got the slightest idea of what features are available on CPAPs, heck they don't know ANYTHING about CPAPs except what their local DME supplier provides and tells them.

I remember something somewhere that might have been early in their sales showing the Escapes hadn't been moving as well as their older models of the s9. That could have been in the first month of their release or my memory could be way off. As far as the cost to make the things....
the Autoset and Elite were the 1st of the line. The Escape required getting their printer to print up a new label for the top and the tooling for that could have cost a few grand. The dumbing down the firmware might have costs man weeks. I expect it cost less to make an Autoset than an Escape even if its a few cents which is what it would be even if they make 100 times more of them.

Pardon my skepticism but it makes NO SENSE AT ALL to manufacture and sell a "dumb" device that is reimbursed at the same rate as a "smart" device.

What local DME provider would buy a "dumb" device that costs more to buy but only worth the same reimbursement fee as a "smart" device???

Nah, I do NOT buy your theory at all.

To approach this from another side. As I understand it, the diff between a Respironics CPAP, and its APAP, and its Bi-Pap machine is only plastic on the outside, and firmware. Likewise the diff in Resmed up to S 9 Auto VPAP is only a bit of plastic and firmware. Any one with specific knowledge please chime in?

If this is true. Why do manufacturers sell crippled machines for less than the best, which a customer may need. I am in big support that company is entitled to receive extra money for better things, including Firmware. After all, if the Firmware is not programmed correctly, then the machines not serve the needs of all of us, including some that got killed.

However. I do not feel that it is a fair market procedure to make the best machine, then cripple it, sell if for less to make insurance companies happy, and to create a price structure. Yes, this includes bricks as well.

I go on to observe, that whatever you needed when you had your sleep study, your settings requirements may change several times, and the best way for the doc, or yourself to know, is a full data capable machine.

Now I need a bi-level machine, however, the Medicare rules say that one can only get a Bi-level, or Bi-Pap machine if one fails CPAP during the sleep study. Hmm. Which might allow some interpretation that would get me to a Bi-Level, but I think not when the Medicare agent can find any reason to deny.

But I raise the point. A lot of others have a need for Bi- machines that might not meet that exact standard that Medicare (thereby other insurers) use. I say that the this standard was created with the thought that the person only had just Apnea Problems, and that the lowest level of care is acceptable. I disagree with that opinion. I think nearly all of us have multiple health conditions which amplify each other. By the time we get on this board, we have discovered the minimal level of treatment that doctors, DME's accept is not sufficient for us to have quality of sleep, thereby, quality of life.

What do we do next? Can we lobby that manufacturers not be allowed to sell crippled machines? How much more would it cost of all machines had Full data, auto, and bi-level capabilities? I suspect that a full-data, Auto, bi machine is over a thousand dollars more is just a fiction made up by profit hungry management team.

And why not make a plug in for a recording Pulse-Oximeter to be standard as well (with alarm) plus to send a decent Pulse Oximeter with the machine as standard.

The 'brick' is preferred by those providers who can make money off unnecessary titrations,
either where the DME is also the lab, or by official referral or kickbacks.
The Autocpap deprives them of the money they desperately need for
those little things that make them feel superior to the other 99% of us.
Another (conspiracy) theory is that use of these machines is discouraged by big Pharma,
for obvious reasons, and easily so, due to their huge slush funds.
Am I reaching too far--or not?

is the s9 resmed vpap different than an apap? if so, how so? because I am also still struggling with aerophagia altho I have been faithfully using my machine. I tried taping mymouth..got it. I tried no tape on my mouth..got it more with dry mouth (and a humidifier)

I must open my mouth to my toes or something. Jeezopeete.

Froggie, I put the blame on the physician who does not specify an APAP instead of CPAP right at the begining. A DME would be happy to charge Medicare or other insurance the higher prices of APAPs.

But some physicians don't want to specify APAPs b/c of the extra diagnosis needed to exclude certain underlying medical conditions.

I have just added the fllowing to my post above in the first page. I am copying it below. What do you think about it?

According to the AASM Report, of 2008, persons with several medical conditions should not be treated with APAPs:


(5) certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes);

Patients with congestive heart failure, significant lung disease such as chronic obstructive pulmonary disease, patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome), patients who do not snore (either naturally or as a result of palate surgery), and patients who have central sleep apnea syndromes are not currently candidates for APAP titration or treatment. (Standard)



Certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes). (Option)

Source:

Practice Parameters for the Use of Autotitrating Continuous Positive Airway Pressure Devices for Titrating Pressures and Treating Adult Patients with Obstructive Sleep Apnea Syndrome: An Update for 2007

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2225554/

To those who feel like jumping and saying that the above Guidelines were in 2007 and the APAPs machines have been modified since then (like RG did), my reply is this:

Take for example the Resmed S9 Autoset. Dr Michael Berthon Jones, Resmed's chief designer of their Autoset machines, applied for patents on the S9 Autoset operation and techniques (such as using the FOT) already in 1994. So any major modifications in this machine after 2007 (when the AASME Guidelines became effective), is doubtful.

You (or others) can see here that the 1994 Patent Application by Michael did cover the S9 Autoset:

Inventor
• Berthon-Jones, Michael
Assignee
• ResMed Limited
Application
No. 335118 filed on 11/04/1994
US Classes:
128/204.23, Means for sensing condition of user's body128/204.21, Electric control means128/207.18, Respiratory gas supply means enters nasal passage600/529Respiratory
Examiners
Primary: Millin, Vincent
Assistant: Raciti, Eric P.
Attorney, Agent or Firm
• Holland & Hart llp
Foreign Patent References
• WO 93/08857 WO. 05/21/1993
• WO 93/09834 WO. 05/21/1993
International Class
A61M 016/00
Foreign Application Priority Data
1993-11-05 AU

Abstract

Methods and apparatus for determining the occurrence of an apnea, patency and/or partial obstruction of the airway are disclosed. Respiratory air flow from a patient is measured to give an air flow signal. The determination of an apnea is performed by calculating the variance of the air flow signal over a moving time window and comparing the variance with a threshold value. One determination of partial obstruction of the airway is performed by detecting the inspiratory part of the air flow signal, scaling it to unity duration and area and calculating an index value of the amplitude of the scaled signal over a mid-portion. Alternatively, the index value is a measure of the flatness of the air flow signal over the mid-portion. One determination of patency of the airway is performed by applying an oscillatory pressure waveform of known frequency to a patient's airway, calculating the magnitude of the component of said air flow signal at the known frequency induced by the oscillatory pressure waveform and comparing the calculated magnitude with a threshold value. Alternatively, the air flow signal is analysed to detect the presence of a component due to cardiogenic activity

Methods and apparatus for determining the occurrence of an apnea, patency and/or partial obstruction of the airway are disclosed. Respiratory air flow from a patient is measured to give an air flow signal. The determination of an apnea is performed by calculating the variance of the air flow signal over a moving time window and comparing the variance with a threshold value. One determination of partial obstruction of the airway is performed by detecting the inspiratory part of the air flow signal, scaling it to unity duration and area and calculating an index value of the amplitude of the scaled signal over a mid-portion. Alternatively, the index value is a measure of the flatness of the air flow signal over the mid-portion. One determination of patency of the airway is performed by applying an oscillatory pressure waveform of known frequency to a patient's airway, calculating the magnitude of the component of the air flow signal at the known frequency induced by the oscillatory pressure waveform and comparing the calculated magnitude with a threshold value. Alternatively, the air flow signal is analysed to detect the presence of a component due to cardiogenic activity.

So, Avi, you do NOT believe that some doctors are influenced by drug reps or friends in the DME and sleep labs?
Good lord, they golf together; and their children intermarry.
The decision to RX APAP is a no-brainer; given the contraindications are absent.
After all, how many APAPs cannot be run on straight CPAP? ZERO!

purple wrote: Now I need a bi-level machine, however, the Medicare rules say that one can only get a Bi-level, or Bi-Pap machine if one fails CPAP during the sleep study. Hmm. Which might allow some interpretation that would get me to a Bi-Level, but I think not when the Medicare agent can find any reason to deny.

Absolutely incorrect, below is the exact wording from the Medicare LCD.

INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.
I.An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:


A.The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.

B.The patient has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
1.The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,

2.The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
a.Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

b.Hypertension, ischemic heart disease, or history of stroke.
C.The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.


II.An E0470 device is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D
D.An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If E0470 is billed for a patient with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.

A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.

If an E0601 device has been used for more than 3 months and the patient is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the E0470.

Coverage, coding and documentation requirements for the use of the E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and Policy Article (PA).



As you can see, failure on the CPAP is not limited to the hospital sleep study.

chunkyfrog wrote:So, Avi, you do NOT believe that some doctors are influenced by drug reps or friends in the DME and sleep labs?

I hope all doctors are influenced by the people you mention. This is part of information gathering and keeping up with current developments.

Good grief, I wish my doctor would sit down regularly with the CPAP manufacturers and get educated about how the machines work while sharing his experience with their new product development team. If they talk about it on the golf course then great!

But chunkyfrog, I think maybe you were talking about a doctor who would let influence and personal gain be a priority over the patient's best interest.