Changing to BiPap and the 'Fellow' who changes his script!!!

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Changing to BiPap and the 'Fellow' who changes his script!!!

Postby Flame » Wed Oct 05, 2011 4:15 pm

I am being switched from Cpap to Bipap. I have only been on Cpap for about 6 weeks @ 18 but wasn't getting enough air. I am still at the rental stage with Medicare.

The new BiPap numbers will be 26 inhale and 20 exhale. I called DME today to find he had changed it to 25-20 without the machine type and without any rationale for medicare as to what machine.The 'fellow' doc I have wrote the initial script wrong, stating the above pressures but prescribing a machine that only goes to 25.

My concern is if he puts me on a machine that only goes to 25 and I need more later---I doubt that Medicare will buy it.

My questions are:
Why in the heck did he change the script for a less expensive machine?
and
What are the criteria for Medicare to change from Cpap to BiPap? (I saw this somewhere but can't find the link)
Thank you!
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Daniel » Wed Oct 05, 2011 4:57 pm

Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.

Do NOT accept this. Demand an explanation IN WRITING without any delay. You should tell your DME that you intend reporting their actions to the relative legal authorities.

Bad enough to be faced with such a high pressure, but having to put up with this type of activity.

Best of luck.

Daniel.
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Unlike his three passengers who died screaming !


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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby robysue » Wed Oct 05, 2011 5:36 pm

Flame wrote:The new BiPap numbers will be 26 inhale and 20 exhale. I called DME today to find he had changed it to 25-20 without the machine type and without any rationale for medicare as to what machine.The 'fellow' doc I have wrote the initial script wrong, stating the above pressures but prescribing a machine that only goes to 25.

My concern is if he puts me on a machine that only goes to 25 and I need more later---I doubt that Medicare will buy it.

My questions are:
Why in the heck did he change the script for a less expensive machine?
and
What are the criteria for Medicare to change from Cpap to BiPap?

Why'd they change the script from 26 to 25cm? Most likely because all plain bi-levels and many bi-level STs and some ASV machines only go up to 25cm. And Medicare often requires that a patient "fail" at bi-level before being willing to pay for the much more expensive bi-level ST and ASV machines.

As for changing the script for a less expensive machine, I'm not sure I follow you. Here's the outline of the various machines and their costs and their max pressure levels as near as I can determine:

    Regular CPAP/APAP machines (i.e. the cheapest PAP machines) typically only go up to 20cm of pressure. Two of the most expensive APAPs are the Resmed S9 APAP and the PR System One Auto. At a well known on-line CPAP supplier, the S9 costs$853 and the System One costs $729.

    Regular BiPAP/VPAP (bilevel machines WITHOUT so-called trigger mode) go up to 25cm of pressure (for the IPAP). These machines are typically are a bit more than twice as expensive as the top of the line APAPs. At that same well known on-line CPAP supplier the Resmed VPAP Auto costs $1959 and the System One BiPAP Auto costs $1949. As for qualifying for Medicare coverage of a bi-level instead of a regular CPAP/APAP? One criteria would be that you need more than 20cm of pressure as certified by your sleep doctor. The need for high pressure levels is actually a pretty common reason for a doctor switching a patient to a bi-level machine. They may need to complete some paperwork justifying the medical necessity of the switch. That can be done based on a patient not tolerating CPAP/APAP sufficiently well. Or, as in your case, it can be done because the patient needs more than 20cm of pressure to keep the airway properly splinted open.

    The next step up are the BiPAP/VPAP ST machines. These machines are MUCH, MUCH more expensive. As in $5000 at that well known on-line CPAP supplier. The ST machines have what is called "trigger mode" where they can be set up to act as a noninvasive ventilator---in other words they can be set up to trigger breathing in a patient that is not breathing on their own. But these machines still only go up to 25cm of pressure.

    The next (and final) step up for PAP-type machines are the so-called ASV (Auto Servo Ventilator) machines. They are even more expensive, but some of them are capable of putting out 30cm of pressure.


These ST and ASV machines are typically prescribed to patients with non-standard forms of sleep apnea: People who have CompSA or Central SA in particular. The ASV machines really are a non-invasive ventilator when set up in ASV mode. And if the problem is plain old OSA, you don't need a non-invasive vent because you're attempting to breath on your own even when the airway is collapse. Ergo, prop the airway open with pressurized air and the patient breaths on their own 100% of the time. In CompSA and Central SA, however, a significant part of the problem is that the patient is simply making no effort to breath at all many, many times a night. Medicare and many insurance companies demand that a CompSA or Central SA patient first "fail" at Bi-level without the trigger before paying for a bi-level ST or ASV machine.
current settings Min EPAP = 4, Max IPAP = 8 and Rise time = 3

8/1/2010 sleep study results:
AHI = 3.9 [AHI = (#OA +#CA + #H w/desat) per hour]
RDI = 23.4 [RDI = (#OA +CA + #H w/desat + #H w/arousal) per hour]
Dx: Moderate OSA
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby robysue » Wed Oct 05, 2011 5:50 pm

Daniel wrote:Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.
Daniel, The OP said the doc was making a switch to a plain old BiPAP. BiPAPs without a Trigger mode do not deliver any more than 25cm of pressure. Period. Nor do BiPAP STs. And the System One BiPAP ASV also only delivers up to 25cm of pressure.

Also the OP does not mention a titration sleep study that led to the IPAP being prescribed at 26cm. More likely since the OP was complaining of not enough air at 18cm with his CPAP, the doc is simply making a seat of the pants guesstimate for the new pressure. And the difference between 25/20 vs 26/20 probably did not strike the doctor, the "fellow" doctor, or the DME as being worthy of more than doubling the cost of the new machine. Now, if there's a titration study that shows the OP really needs an IPAP = 26, that's a whole 'nother ball game.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.
The OPs doc apparently specified a Resmed System One BiPAP of some sort in the prescription. And all of the PR System One BiPAPs (The BiPAP Pro, the BiPAP Auto, the BiPAP ST, or the BiPAP ASV) have a max pressure setting of 25cm. Indeed, I believe that anything that's capable of delivering more than 30cm of pressure is considered to be a full fledged ventilator, albeit it does not need to be an invasive vent. And there are real reasons why the medical establishment would rather not put someone on a full fledged vent, even a noninvasive one, until it is proven that's what they need.
current settings Min EPAP = 4, Max IPAP = 8 and Rise time = 3

8/1/2010 sleep study results:
AHI = 3.9 [AHI = (#OA +#CA + #H w/desat) per hour]
RDI = 23.4 [RDI = (#OA +CA + #H w/desat + #H w/arousal) per hour]
Dx: Moderate OSA
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Flame » Wed Oct 05, 2011 6:37 pm

Daniel wrote:Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.

Do NOT accept this. Demand an explanation IN WRITING without any delay. You should tell your DME that you intend reporting their actions to the relative legal authorities.

Bad enough to be faced with such a high pressure, but having to put up with this type of activity.

Best of luck.

Daniel.


Thank you so much Daniel. I called the university DME and the techs were actually sitting there talking about me. They stated that his 'fellow' is very new and that my situation should be taken up with the attending. They questioned the original why this was so poorly managed in the first place. According to the respiratory therapist I need a ______ (can't remember--didn't sound familiar) that is $10,000 and Medicare will need allot of paperwork.

thanks you for helping me realize I have to fight for this even if I have to wait. I have to have what I need even if I need yet another titration.

robysue wrote:
Daniel wrote:Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.
Daniel, The OP said the doc was making a switch to a plain old BiPAP. BiPAPs without a Trigger mode do not deliver any more than 25cm of pressure. Period. Nor do BiPAP STs. And the System One BiPAP ASV also only delivers up to 25cm of pressure.

Also the OP does not mention a titration sleep study that led to the IPAP being prescribed at 26cm. More likely since the OP was complaining of not enough air at 18cm with his CPAP, the doc is simply making a seat of the pants guesstimate for the new pressure. And the difference between 25/20 vs 26/20 probably did not strike the doctor, the "fellow" doctor, or the DME as being worthy of more than doubling the cost of the new machine. Now, if there's a titration study that shows the OP really needs an IPAP = 26, that's a whole 'nother ball game.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.
The OPs doc apparently specified a Resmed System One BiPAP of some sort in the prescription. And all of the PR System One BiPAPs (The BiPAP Pro, the BiPAP Auto, the BiPAP ST, or the BiPAP ASV) have a max pressure setting of 25cm. Indeed, I believe that anything that's capable of delivering more than 30cm of pressure is considered to be a full fledged ventilator, albeit it does not need to be an invasive vent. And there are real reasons why the medical establishment would rather not put someone on a full fledged vent, even a noninvasive one, until it is proven that's what they need.


I'm not sure of all the things you said because I am new. What I can say is that this was my third titration attempt and they ran out of time at 26-20. My hunch is that this 'fellow' just wrote that number because the secretary told him I needed a different machine when it was over 26. I don't feel confident at all at this point and am willing to wait until it's right. Meanwhile, I keep using my cpap and continue with compliance.

robysue wrote:
Flame wrote:The new BiPap numbers will be 26 inhale and 20 exhale. I called DME today to find he had changed it to 25-20 without the machine type and without any rationale for medicare as to what machine.The 'fellow' doc I have wrote the initial script wrong, stating the above pressures but prescribing a machine that only goes to 25.

My concern is if he puts me on a machine that only goes to 25 and I need more later---I doubt that Medicare will buy it.

My questions are:
Why in the heck did he change the script for a less expensive machine?
and
What are the criteria for Medicare to change from Cpap to BiPap?

Why'd they change the script from 26 to 25cm? Most likely because all plain bi-levels and many bi-level STs and some ASV machines only go up to 25cm. And Medicare often requires that a patient "fail" at bi-level before being willing to pay for the much more expensive bi-level ST and ASV machines.

As for changing the script for a less expensive machine, I'm not sure I follow you. Here's the outline of the various machines and their costs and their max pressure levels as near as I can determine:

    Regular CPAP/APAP machines (i.e. the cheapest PAP machines) typically only go up to 20cm of pressure. Two of the most expensive APAPs are the Resmed S9 APAP and the PR System One Auto. At a well known on-line CPAP supplier, the S9 costs$853 and the System One costs $729.

    Regular BiPAP/VPAP (bilevel machines WITHOUT so-called trigger mode) go up to 25cm of pressure (for the IPAP). These machines are typically are a bit more than twice as expensive as the top of the line APAPs. At that same well known on-line CPAP supplier the Resmed VPAP Auto costs $1959 and the System One BiPAP Auto costs $1949. As for qualifying for Medicare coverage of a bi-level instead of a regular CPAP/APAP? One criteria would be that you need more than 20cm of pressure as certified by your sleep doctor. The need for high pressure levels is actually a pretty common reason for a doctor switching a patient to a bi-level machine. They may need to complete some paperwork justifying the medical necessity of the switch. That can be done based on a patient not tolerating CPAP/APAP sufficiently well. Or, as in your case, it can be done because the patient needs more than 20cm of pressure to keep the airway properly splinted open.

    The next step up are the BiPAP/VPAP ST machines. These machines are MUCH, MUCH more expensive. As in $5000 at that well known on-line CPAP supplier. The ST machines have what is called "trigger mode" where they can be set up to act as a noninvasive ventilator---in other words they can be set up to trigger breathing in a patient that is not breathing on their own. But these machines still only go up to 25cm of pressure.

    The next (and final) step up for PAP-type machines are the so-called ASV (Auto Servo Ventilator) machines. They are even more expensive, but some of them are capable of putting out 30cm of pressure.


These ST and ASV machines are typically prescribed to patients with non-standard forms of sleep apnea: People who have CompSA or Central SA in particular. The ASV machines really are a non-invasive ventilator when set up in ASV mode. And if the problem is plain old OSA, you don't need a non-invasive vent because you're attempting to breath on your own even when the airway is collapse. Ergo, prop the airway open with pressurized air and the patient breaths on their own 100% of the time. In CompSA and Central SA, however, a significant part of the problem is that the patient is simply making no effort to breath at all many, many times a night. Medicare and many insurance companies demand that a CompSA or Central SA patient first "fail" at Bi-level without the trigger before paying for a bi-level ST or ASV machine.


I don't think I worded it very well. What I meant was that he just 'off the cuff' changed the pressure instead of changing the machine. He is new so maybe he isn't familiar with someone with complex SA. Do you think I will need another 'titration' starting at 26 and going up? I'm wondering if that will be the case. Hopefully, the attending will take over.
robysue wrote:
Daniel wrote:Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.
Daniel, The OP said the doc was making a switch to a plain old BiPAP. BiPAPs without a Trigger mode do not deliver any more than 25cm of pressure. Period. Nor do BiPAP STs. And the System One BiPAP ASV also only delivers up to 25cm of pressure.

Also the OP does not mention a titration sleep study that led to the IPAP being prescribed at 26cm. More likely since the OP was complaining of not enough air at 18cm with his CPAP, the doc is simply making a seat of the pants guesstimate for the new pressure. And the difference between 25/20 vs 26/20 probably did not strike the doctor, the "fellow" doctor, or the DME as being worthy of more than doubling the cost of the new machine. Now, if there's a titration study that shows the OP really needs an IPAP = 26, that's a whole 'nother ball game.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.
The OPs doc apparently specified a Resmed System One BiPAP of some sort in the prescription. And all of the PR System One BiPAPs (The BiPAP Pro, the BiPAP Auto, the BiPAP ST, or the BiPAP ASV) have a max pressure setting of 25cm. Indeed, I believe that anything that's capable of delivering more than 30cm of pressure is considered to be a full fledged ventilator, albeit it does not need to be an invasive vent. And there are real reasons why the medical establishment would rather not put someone on a full fledged vent, even a noninvasive one, until it is proven that's what they need.


There was a third titration that led to the 26/20 number. However, they ran out of time in my opinion. The reason it was done is that I kept telling everyone that I wasn't getting any air. At 18 I didn't really feel it.

The respiratory therapist I just talked to said the machine I need is $10,000. So, I have no idea what that would be. I can't find any machine that expensive at any of the online stores. Would this be a ventilator minus the intubation part?

Thank you so much to all of you

Lois
Complex Apnea AHI: 78.1
Periodic Limb Movement: 118

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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Flame » Wed Oct 05, 2011 6:41 pm

robysue wrote:
Daniel wrote:Don't know the story with Medicare.....BUT giving you a machine that maxes out at 25, for a script of 26 is criminal. To amend the prescription to suit machines in stock is NOT acceptable.
Daniel, The OP said the doc was making a switch to a plain old BiPAP. BiPAPs without a Trigger mode do not deliver any more than 25cm of pressure. Period. Nor do BiPAP STs. And the System One BiPAP ASV also only delivers up to 25cm of pressure.

Also the OP does not mention a titration sleep study that led to the IPAP being prescribed at 26cm. More likely since the OP was complaining of not enough air at 18cm with his CPAP, the doc is simply making a seat of the pants guesstimate for the new pressure. And the difference between 25/20 vs 26/20 probably did not strike the doctor, the "fellow" doctor, or the DME as being worthy of more than doubling the cost of the new machine. Now, if there's a titration study that shows the OP really needs an IPAP = 26, that's a whole 'nother ball game.

There are machines (not sure of manufacturer) that go to 35.....that is what you require.
The OPs doc apparently specified a Resmed System One BiPAP of some sort in the prescription. And all of the PR System One BiPAPs (The BiPAP Pro, the BiPAP Auto, the BiPAP ST, or the BiPAP ASV) have a max pressure setting of 25cm. Indeed, I believe that anything that's capable of delivering more than 30cm of pressure is considered to be a full fledged ventilator, albeit it does not need to be an invasive vent. And there are real reasons why the medical establishment would rather not put someone on a full fledged vent, even a noninvasive one, until it is proven that's what they need.


I forgot to mention that he didn't specify a machine, at least that's what I was told---and all he said was "needs a pressure change" Oh brother, I could have told them that.
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Daniel » Wed Oct 05, 2011 9:18 pm

Daniel, The OP said the doc was making a switch to a plain old BiPAP. BiPAPs without a Trigger mode do not deliver any more than 25cm of pressure. Period. Nor do BiPAP STs. And the System One BiPAP ASV also only delivers up to 25cm of pressure.

Also the OP does not mention a titration sleep study that led to the IPAP being prescribed at 26cm. More likely since the OP was complaining of not enough air at 18cm with his CPAP, the doc is simply making a seat of the pants guesstimate for the new pressure. And the difference between 25/20 vs 26/20 probably did not strike the doctor, the "fellow" doctor, or the DME as being worthy of more than doubling the cost of the new machine. Now, if there's a titration study that shows the OP really needs an IPAP = 26, that's a whole 'nother ball game.


I think you may be getting a little too technical here.
The OP has pretty much corrected your statements here.
I didn't see any mention of an arbitary change in pressure.....merely an adjustment to a script.
I also suggest that you look at the NIPPY machine, which is practically used exclusively for COPD type patients (is also suitable for OSA and CSA) and delivers an IPAP of up to 38 cmsH2O (sorry I said 35 in my post....wrong by 3 cmsH2O LOL)

http://www.nippyventilator.com/html/nippy_st_.html

There are also other 'stricly respiratory type machines' that deliver IPAP pressures up to 35 cmsH2O.............don't have time to search them out......BUT I know that they do exist.

I don't believe the purpose of this thread is to get caught up in technical stuff, which can be time consuming and gets us away from the primary point......a script for an IPAP of 26, being reduced to 25...apparantly to suit a machine that maxes out at 25, when there are suitable machines available that will deliver up to 38 cmsH2O.............NOT a very good outcome for the patient, who is our primary concern.

Daniel.
The untreated Sleep Apnoea sufferer died quietly in his sleep..
Unlike his three passengers who died screaming !


The first 40 years of childhood are by far the hardest
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Flame » Wed Oct 05, 2011 9:56 pm

Daniel, thank you so much, it will help me have the courage to advocate for myself!
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Mrs Rip Van Winkle » Sat Oct 08, 2011 8:28 pm

I dare to guess that the $10,000 machine that was mentioned to you is an ASV. These are best for your Complex apnea. Medicare (and other US insurances) typically make you 'fail' a lessor machine before they will approve an ASV.
I'm only a sufferer, not a medical pro. What I post are my thoughts as a sufferer, not that of the ASAA. As a moderator on these forums I oversee the posting rules. This is the internet, always discuss what you read with your medical team.
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Re: Changing to BiPap and the 'Fellow' who changes his scrip

Postby Flame » Sun Oct 09, 2011 6:09 pm

Mrs Rip Van Winkle wrote:I dare to guess that the $10,000 machine that was mentioned to you is an ASV. These are best for your Complex apnea. Medicare (and other US insurances) typically make you 'fail' a lessor machine before they will approve an ASV.


I just looked at those and they most likely are referring to those. They may have to put me in a less expensive unit before I 'graduate' to the ASV. So many of these machines only go to 25, I have only found a couple that go to 30----surely there are machines that are much higher.

Thanks again
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