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Permalink Reply by Judy on October 9, 2009 at 11:12pm

A bi-level device (Bi-PAP is Respironics proprietary name for the bi-levels and VPAP is Resmed's proprietary name for their bi-levels) is not the same insurance (HCPCS) code as the CPAPs and APAPs (auto paps). Bi-levels are considerably more expensive than CPAPs and APAPs and insurances seldom pay for a bi-level unless the patient "fails" CPAP therapy.

The IMPORTANT difference amongst the various CPAP/APAP models is full data capability. Some devices are capable of providing only compliance data, i.e. the number of hours used per night, number of nights used and number of nights used since first being used plus total hours the device has been used. That compliance data has absolutely no use to anyone EXCEPT the local DME provider to be able to provide proof the device is being used to the insurance company to receive payment. You do NOT want to accept a compliance data capable only device!!!

The fully data capable CPAPs and APAPs provide Efficacy data as well as compliance data. Efficacy data includes pressure, leak rate, apnea/hypopnea index and apnea index for the previous night and for some other time periods as well depending on the manufacturer. THIS is the data that enables you and/or your doctor to determine any problems you may be having w/CPAP therapy so that any necessary changes can be made based on the data rather than by guess and by gosh.

Most brands and models of CPAPs and APAPs provide a Ramp feature that allows the device to start out at a low pressure and gradually build up to your therapeutic pressure over a set time period, usually set for the length of time it normally takes you to fall asleep.

The two major manufacturers, Respironics and Resmed, also offer a feature providing exhalation pressure relief. Respironics propreitary name for this expiration pressure relief is C-Flex and A-Flex; Resmed's proprietary name is EPR. These forms of expiration pressure relief can provide up to 3 cms less pressure upon sensing the user exhaling, then return to therapeputic pressure upon inhalation. This is somewhat like a "mini bi-level". (Bi-levels can produce a greater range of pressure for inhalation and exhaltion).

APAPs (auto PAPs) are classified as CPAPs and are the same insurance (HCPCS) code for insurance reimbursement purposes. However, they are capable of running in two modes: as a straight CPAP or as an auto-titrating PAP. In auto mode instead of a set pressure there are two pressure settings, a minimum and a maximum, and the pressure provided can vary as needed w/in that pressure range. The patient might not always need the highest pressure setting the entire night and may only need the highest pressure when an apena or hypopnea occurs. The device only provides the highest pressure to treat an "event" when needed allowing the patient to spend the better part of the night at a somewhat lower pressure.

An APAP is a nice "bonus" for its auto titration feature but many patients find the constant pressure changes interrupt or inhibit restful sleep and usually run their device in CPAP mode the majority of the time, using the auto mode only when they want a "mini-home-titration" to verify a possibly pressure change need.

INSIST on a fully data capable CPAP. Just because a CPAP has a data card does NOT mean that it is fully data capable.

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Permalink Reply by Jan on October 9, 2009 at 11:57pm

Thanks, Judy. This is very helpful. I am finally understanding the distinction. I thought that only bi-level machines offered relief on exhalation and now understand that while the bi-levels offer the most flexibility and range for decreasing the air pressure on exhalation, that other machines have this capability-- just to a lesser extent.

Thanks! I sincerely appreciate the time you spent explaining this.

Jan


Judy said:

A bi-level device (Bi-PAP is Respironics proprietary name for the bi-levels and VPAP is Resmed's proprietary name for their bi-levels) is not the same insurance (HCPCS) code as the CPAPs and APAPs (auto paps). Bi-levels are considerably more expensive than CPAPs and APAPs and insurances seldom pay for a bi-level unless the patient "fails" CPAP therapy.

The IMPORTANT difference amongst the various CPAP/APAP models is full data capability. Some devices are capable of providing only compliance data, i.e. the number of hours used per night, number of nights used and number of nights used since first being used plus total hours the device has been used. That compliance data has absolutely no use to anyone EXCEPT the local DME provider to be able to provide proof the device is being used to the insurance company to receive payment. You do NOT want to accept a compliance data capable only device!!!

The fully data capable CPAPs and APAPs provide Efficacy data as well as compliance data. Efficacy data includes pressure, leak rate, apnea/hypopnea index and apnea index for the previous night and for some other time periods as well depending on the manufacturer. THIS is the data that enables you and/or your doctor to determine any problems you may be having w/CPAP therapy so that any necessary changes can be made based on the data rather than by guess and by gosh.

Most brands and models of CPAPs and APAPs provide a Ramp feature that allows the device to start out at a low pressure and gradually build up to your therapeutic pressure over a set time period, usually set for the length of time it normally takes you to fall asleep.

The two major manufacturers, Respironics and Resmed, also offer a feature providing exhalation pressure relief. Respironics propreitary name for this expiration pressure relief is C-Flex and A-Flex; Resmed's proprietary name is EPR. These forms of expiration pressure relief can provide up to 3 cms less pressure upon sensing the user exhaling, then return to therapeputic pressure upon inhalation. This is somewhat like a "mini bi-level". (Bi-levels can produce a greater range of pressure for inhalation and exhaltion).

APAPs (auto PAPs) are classified as CPAPs and are the same insurance (HCPCS) code for insurance reimbursement purposes. However, they are capable of running in two modes: as a straight CPAP or as an auto-titrating PAP. In auto mode instead of a set pressure there are two pressure settings, a minimum and a maximum, and the pressure provided can vary as needed w/in that pressure range. The patient might not always need the highest pressure setting the entire night and may only need the highest pressure when an apena or hypopnea occurs. The device only provides the highest pressure to treat an "event" when needed allowing the patient to spend the better part of the night at a somewhat lower pressure.

An APAP is a nice "bonus" for its auto titration feature but many patients find the constant pressure changes interrupt or inhibit restful sleep and usually run their device in CPAP mode the majority of the time, using the auto mode only when they want a "mini-home-titration" to verify a possibly pressure change need.

INSIST on a fully data capable CPAP. Just because a CPAP has a data card does NOT mean that it is fully data capable.

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Permalink Reply by Judy on October 10, 2009 at 8:04am

You are more than welcome, Jan. It was a concept many of us have some trouble grasping at first. As I said, the most important feature is full data capability.

The local DME suppliers usually prefer to provide the bare bone compliance data only capable devices because they are a little cheaper than the fully data capable CPAPs. I'm not sure the difference in cost to the local DME providers, it used to be about $40. And then the APAPs cost them a little more than the fully data capable CPAPs. But their reimbursement from insurances is the same irregardless of the cost to them. But they take that into consideration when they contract w/the insurances for one set price for ANY HCPCS code xPAP. (We use xPAP to indicate ANY PAP device).

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Permalink Reply by Jan on October 10, 2009 at 9:32am

WOW WOW WOW!!! I think I am finally getting why the DME's are frequently customer unfriendly. The more sophisticated machines cost them more money, but the insurance companies reimburse the same amount for a plain vanilla as they do for the most sophisticated machines. sheesh!!!

I am quoting Mike here (founder of Sleepguide) from an article he wrote on this site, and would like to take his suggestions regarding the following:

"Tough to hear, but yes, having Sleep Apnea means you will at one point or another have to shell out dough out of your own pocket. We Americans have an attitude that when it comes to maintaining our cars or our lawns, it's normal to pay something to keep these things in good order, but that when it comes to our own bodies and health, someone else, whether it be insurance companies or Medicare, has to foot the bill. Granted, we pay taxes and insurance premiums to cover this stuff, but the hard cold truth is that it won't foot the entire bill. We can agitate for better health care, but in the meantime, we need to take ownership over our lives and pay the difference between what insurance and Medicare will pay and what it will not.

Once we have this consumer mindset toward our own health, we gain more control and can be more proactive. Data capable machines are better to get than dumb black boxes. Auto-adjusting machines give you more options than "straight" machines. The latest mask on the market repre sents the latest technology in making these things comfortable to use, and will most likely be easier to use than the one that's in your closet not being used because it makes the bridge of your nose sore. You can get all this stuff online, if you're willing and able to fork over the cash."

and he further suggests:

"Get a copy of your full sleep study and titration reports. Then ask your doctor for, and obtain, as open-ended a prescription for a PAP device and mask as possible --20doctors can write a script for, say, a "ResMed Mirage Micro Nasal Face Mask" (specific), or they can simply write a script for "a mask according to patient's comfort and choice" (open-ended). Make sure they write the latter. Armed with your full sleep report and open-ended prescriptions (which you should keep in a safe place, by the way), you'll give yourself the ability to double check on things and get advice from everyone in the world you trust, including the people on this forum. In other words, you'll give yourself options and control."

With this in mind, I am seeing my doctor this week to review results of titration study. I have a long term relationship with this doctor and believe that he will write the prescription in any way I want him to that is ethical. I am willing to pay out of pocket to either purchase or subsidize the best possible machine, masks etc that will make it easiest for me to comply.

I know that the selection of this equipment can be trial and error but am wondering how I should best ask my doctor to write the prescription so that I can start with the best shot out of the box (most flexibility for that trial and error) etc.

Thanks so much for your (and everyone's) continued assistance!
Jan

P.S. Sorry for such a long post--

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Permalink Reply by Duane McDade on October 10, 2009 at 10:01am

The autos cause more problems than they solve, but it's better than nothing.

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Permalink Reply by Judy on October 10, 2009 at 10:16am

Forgive me, Duane McDade, but I do have to disagree w/you about APAPs. An APAP can always be used in straight CPAP mode. But a straight CPAP can't be used as an APAP. There are those few who even do better in constant APAP mode. But mostly, its a case of an APAP being able to do an in-home "titration" if pressure needs change IF the sleep doctor will pay ANY attention to the data they provide and thus another expensive in-lab titration can be avoided, this is especially important when one is limited to the interval between insurance covered in-lab PSGs and a change is needed sooner.

Don't misunderstand, I confisder full data capability of PRIME importance and if I had to choose between a fully data capable CPAP and a non-data capable APAP I would have no problem IMMEDIATELY choosing the fully data capable CPAP over that type of APAP in a heartbeat.

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Permalink Reply by RockRpsgt on October 10, 2009 at 10:36am

You are both right. Yes having a machine that has both settings is better than having one that does not. Auto mode is good fro tweeking, or fine tuning your therapy. using auto mode all of the time is not as good for you as a straight pressure that eliminates all events. You have to be very strict with your auto range or this setting will allow you to have more events than a straight CPAP setting. Auto mode will also sometimes cause arousals in patients. By definition the auto algorithm has to have events to work properly. In my opinion if not used right auto mode can actually make you worse. Key words "if not used right". Auto mode is an advanced user mode.

Full Data Capability is the most important thing to look for in a machine.

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Permalink Reply by RockRpsgt on October 10, 2009 at 10:41am

Oh and by the way screw the DME if they are not customer friendly. They are making plenty of money off of you. Get what you want or move on.

1800cpap.com

Ask for Joe K, and tell them Rocky sent you. they will negotiate price. If you have ANY problems let me know and I will fix it.

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Permalink Reply by Jan on October 10, 2009 at 11:10am

I buy lots of stuff on the Internet-- but I thought that these machines had to be set up specifically for me and that someone needed to show me how to use it? Put on the masks best? etc etc? Do the DME's do thawt?

And thanks so much for all of your assistance here.

Rock Hinkle said:

Oh and by the way screw the DME if they are not customer friendly. They are making plenty of money off of you. Get what you want or move on.

1800cpap.com

Ask for Joe K, and tell them Rocky sent you. they will negotiate price. If you have ANY problems let me know and I will fix it.

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Permalink Reply by RockRpsgt on October 10, 2009 at 12:04pm

The DMEs are supposed to do that. I was just giving you an alternative.

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Permalink Reply by Duane McDade on October 10, 2009 at 11:42pm

I have seen it way to often to lay down on this Judy. I can out titrate any AUTO-PAP everytime. Any Tecnician worth his weight in used tires can. A little tube attached to a computer can not see what sleep techs can with our test equipment. we have 10 times the data to use. We have eyes ears ..I dont know what I would do with a little tube ....I guess I could make some sort of crazt straw or something? I have had to re-titrate patients who where ready to give up on a good nights sleep to many times to think that AUTO -PAPS are a better way. Sorry but everything I wrote is true. I can prove it 100+ times.

Judy said:

Forgive me, Duane McDade, but I do have to disagree w/you about APAPs. An APAP can always be used in straight CPAP mode. But a straight CPAP can't be used as an APAP. There are those few who even do better in constant APAP mode. But mostly, its a case of an APAP being able to do an in-home "titration" if pressure needs change IF the sleep doctor will pay ANY attention to the data they provide and thus another expensive in-lab titration can be avoided, this is especially important when one is limited to the interval between insurance covered in-lab PSGs and a change is needed sooner.

Don't misunderstand, I confisder full data capability of PRIME importance and if I had to choose between a fully data capable CPAP and a non-data capable APAP I would have no problem IMMEDIATELY choosing the fully data capable CPAP over that type of APAP in a heartbeat.

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Permalink Reply by Judy on October 11, 2009 at 12:38pm

Yeah, well, Duane, I'm all in favor of an in-lab titration, do NOT misunderstand me!!! But there are times when there are extenuating circumstances. AND not every RPSGT is as good as you. PLUS one night of crappy sleep in a sleep lab sometimes just doesn't give the RPSGT the sleep time to find the right pressure(s) and who can afford repeated in-lab titrations UNTIL some decent sleep time is achieved, whose insurance would pay for them?

My first titration I only slept 42 minutes out of 6 hours bedtime and my second titration I only slept 98 minutes out of six hours bedtime. I was awake and not sleeping at the 6 hour mark both times. How many sleep labs would have allowed me to continue laying there UNTIL I DID put in enough sleep time??? How long would YOU have stayed after waiting for me to HOPEFULLY go back to sleep and sleep long enough to get me titrated to my ideal pressure need??? Would your sleep lab manager have even allowed that?

I didn't go thru one full sleep cycle the first in-lab titration and I'd have to go look at my report to see if I even barely made it thru one full sleep cycle the second time. I rather doubt it but maybe.

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