Medicare Denial

[Sleeprider]

Kidnap Wrote: On 10-19-2016 Sleeprider stated.  "Now the more sobering response. Your sleep study indicates you have complex or mixed apnea. The biggest advantage of the Autoset is that it is going to give you very good data in the event you have the expected difficulty, and likely failure with CPAP. I wish the best success with the APAP, but an ASV is likely in your future."

Sleeprider was so correct! After over 3 months of AHI between 15 & 29 and Centrals between 4 & 6 my family doctor referred me to a Pulmonary sleep specialist with a recommendation of ASV machine. He really wants conformation and bigger clout with Medicare. I'll update you after the 1/30/17.

Kidnap, it's been a while since we heard from you.  I hope you will keep us posted on your progress.  It might be instructive if you posted a typical chart from your CPAP endeavors.  We get a surprising number of people here that present with complex apnea, and your story is important in showing how this has to move (slowly) through the medical system.  I'm glad to hear you are on your way towards appropriate equipment.

In other news, Remworks went out of business in December, so I have had to change DMEs as well.

[Sleeprider]

A quick after-thought to this post. You should start now to plant the idea with your doctor and DME, you want a Resmed Aircurve 10 ASV. I have seen much greater success and comfort using that machine, compared to the Philips Respironics Auto S/V Advanced. You may be given a choice, but since these machines are kind of rare, you might want to express your preference early.

[Kidnap]

Thanks SleepRider,

  First my attempt at data from SleepyHead, although the numbers are always lower than in DreamMapper for some reason. Maybe it doesn't take wake up times into account?

CPAP Usage                             Best AHI                                   Worst AHI                                     
Days Used: 97                         Date: 11/10/2016 AHI: 4.10    Date: 1/8/2017 AHI: 27.87       
Low Use Days: 2                      Date: 11/11/2016 AHI: 5.67    Date: 1/14/2017 AHI: 24.91     
Compliance: 97.9%                 Date: 10/22/2016 AHI: 6.49    Date: 12/25/2016 AHI: 24.34  
Days AHI of 5 or greater: 96    Date: 10/24/2016 AHI: 6.60    Date: 12/17/2016 AHI: 23.00
                                                Date: 10/25/2016 AHI: 6.74    Date: 1/15/2017 AHI: 22.86

Screen dump failed.

I am planning to ask for the Resmed 10 ASV. My new DME is mail order Verus from Nashville TN. I will have to have the Doctor specify it in advance.

[Sleeprider]

You've done well to stick with it. You're going to be amazed at the difference. A number of members here use the ASV machine, and I'm sure they will be helpful when you finally get one.

[Kidnap]

Hi All,

    I went to the pulmonary doctor yesterday. His nurse took my info and remembered that I was the guy with U.S. Medicare problems. She was the nurse who set me up with the home sleep study equipment. I then did remember her. She recovered all the do I sleep standing on my head, at a traffic light or watching TV etc, etc, etc. She took my Blood Pressure, height & weight. I had just a short wait for Dr. P. to arrive. I was quickly put at ease,. He was outgoing, friendly and thorough. He went over my complete history. I passed my first sleep study in 2009 so why did I need another in 2015? I replied my wife still complained of my frequent breathing cessation & my elevated hematocrit levels. He knew al about my Medicare fiasco. I told him I had talked to some friends who know a lot about cpap therapy ( that's you guys on the apneaboard especially SleepRider ). Now here is where it could have gone bad, some doctors egos can get in the way! I said it seams that I need ASV. He said "So do I." He has to prove it to Medicare so I'm scheduled for another sleep study. They got me in tomarrow night, Yipie ki oh, ki yea!
His order says. Reason for test "Previously Diagnosed Sleep Apnea Failed Previous Treatment" - Type of Study "BiPAP AVAPS / iVAPS"
I looked this up and it seams to be the algorithms for both ResMed & Phillips Respironics. must be compairing them.

sorry for the long story
thanks

[Sleeprider]

Wow, great encounter, and result. Both companies produce VPAP/BiPAP, AVAPS, ASV and IVAPS. Be sure to ask about the ASV or SV Advanced that seems to be missing from your list. AVAPS and IVAPS are variations of the ST model machines. ASV has the ability to provide the pressure support on a breath by breath basis ranging from 0 to 20, while providing variable EPAP pressure. I've said it before, and will repeat one more time, I have seen a lot more success and comfort on the Resmed machines in this class.

Good luck!

[Kidnap]

The sleep study was uneventful but they did say my test was for ASV. They used a Respironics Lab Model. The Tech didn't give me any info but I got the Dr.s report vie MyUPMC web site last night. I still don't know if MediCare will approve it but here's the results.

I recieved my sleep study results & recomendation. Not quite what I'd hoped for but very good, a Respironics BiPAP Auto SV, ResMed F20, a heated humidifier and a 20 minute ramp.
Now I have to wait for the DME to call & explain the logistics. I may have to return my old CPAP to the old DME and I don't know who will handle my complience data.

For those who are interested here is the pulmonologist's report. :

"ATTENDING PHYSICIAN: Dr. Dxxxxx Sxxxxx DATE OF STUDY: 02.01.17 PATIENT HISTORY: The patient is a 69 year old male who is 71 inches tall and weighs 175 pounds. The patient was referred to the Center for Sleep Disorders for complex sleep apnea syndrome and essential hypertension. The patient has an Epworth Sleepiness Scale score of 0. NOCTURNAL POLYSOMNOGRAPHY: Full montage polysomnography was accomplished utilizing 6 channels of EEG, 2 channels of EOG, 3 channels of submental EMG, ECG, right and left tibial EMG, thoracic and abdominal effort gauges, a pressure tracing from the PAP unit as indices of airflow and pulse oximetry. PAP TITRATION: Sleep architecture and efficiency: The study was performed for the purpose of positive airway pressure (PAP) titration. During the PAP titration, the patient slept 315.5 minutes out of 366.5 minutes to yield a decreased sleep efficiency of 86%. The architecture of sleep stages was abnormal. Stage one was decreased at 2.2% of TST, stage two was normal at 53.1% of TST, delta sleep was increased at 36.0% of TST, and REM stage sleep was decreased at 8.7% of TST. The latency to persistent sleep was decreased at 8.0 minutes. The latency to REM stage sleep was increased at 182.0 minutes. Sleep fragmentation: There was slight sleep fragmentation with 27 arousals and 4 awakenings greater than one minute to yield an arousal and awakening index of 5.9 events per hour. PAP titration: ASV was titrated to Max Pressure: 25cmH2O/Maximum EPAP: 15cmH2O/Minimum EPAP: 8cmH2O/MaximumPS: 17cmH2O/MinimumPS: 0cmH2O/Rate: Auto. Oxyhemoglobin saturation levels remained above 90%.tolPAP Electrocardiogram: The electrocardiogram was without evidence of arrhythmia. Limb movements: There were 57 periodic limb movements during sleep, none of which were associated with arousals to yield a jerk with arousal index of no events per hour. IMPRESSION: 1. Previous diagnosis of Obstructive Sleep Apnea. 2. Adequate trial of positive pressure therapy. 3. The electrocardiogram was without evidence of arrhythmia. RECOMMENDATION: The patient should be started on a Respironics BiPAP Auto SV titrated to Max Pressure25cmH2O/MaxEPAP: 15cmH2O/MinEPAP: 8cmH2O/MaxPS: 17cmH2O/MinPS: 0cmH2O/Rate: Auto with a ResMed F20, a heated humidifier and a 20 minute ramp. The patient should follow up with the ordering physician to determine compliance with and efficacy of positive pressure therapy and also to discuss the significance of the above findings. "

[Sleeprider]

Although the study specifies Respironics BiPAP Auto SV You should ask about a Resmed Aircurve 10 ASV.  Simply put, I have seen much greater success with the Resmed machines.  They are equivalent technology, but Resmed follows breathing better.  I see no reason why a brand should be specified in the prescription.

the titration results allow up to IPAPmax 25 and an EPAPmin of 15 with PS 0-8 cm.  This can be done on the Resmed of course.  The EPAPmin is quite a bit higher than I would have guessed, and I won't be surprised to see you able to reduce that, especially with a more responsive Resmed...I guess my preference is kind of clear.   Anyway, that EPAPmin is there for obstructive events and is probably set pretty conservatively.

Good luck with the new therapy approach.  It sure looks like you'll be getting a ASV one way or the other.

[Kidnap]

All I can do is ask the DME when they call. I'm sure the Dr. won't care. If nothing else the ResMed has a lot smaller footprint on my nightstand.
 
The first CPAP was decided by the tech who delivered it. Yes, I'll try.

[BadGoodDeb]

If the doctor is agreeable, and if he doesn't care, as you say .... then ask him to SPECIFY the unit you want. The DME is likely to give you the unit which is most cost-beneficial to the DME. He's thinking of himself, not of you. The doctor's orders Rule, so if he says ResMed, the DME can't argue.