Hello Everyone,

It seems now that forums uniting patients are the only source for accurate, but most important, truthful medical advice and experience.  The american system as a whole is broken beyond repair.  Kudos for this forum.  People may not realize how helpful a forum like this is for some.
Here's a scenario help with would be most appreciated.  
Background:  Patient having breathing difficulties awake as well as sleep lab diagnosed severe obstructive sleep apnea but doctor says sleep lab titration study usually shows issues like diaphramatic dysfunction, etc. where bipap may be indicated and titration study did not.  However, when patient lies on back, feels respiratory distress much more, awake or asleep.  Person receives a Resmed S8 Escape around 10-07, a straight cpap at pressure 8, keeping in mind person has medicare.  Medicare apparently has a capped rental policy of 13 months, whereafter the patient owns the device.  Patient is completely new to pap and related insurance issues.  Patient not sleeping well at all though not waking up choking like before, doesn't know all the reasons, but especially feels distress trying to exhale against the pressure (mask fit and humidification not a problem).  5 months later 2 week trial with Resmed Autopap pressure 5 to 15, which shows pressure should be 10 something probably because of weight change.  Patient fights with DME company because doctor writes a medical necessity script for Resmed S8 Vantage (autopap) 5 to 12, but DME company says medicare doesn't cover autopap and customarily charges patients a fee (around $200) out of pocket for machines with additional features, which is fraudulent because apparently medicare does cover autopap with medical necessity just not the way DME companies would like because autopap is billed and therefore reimbursed to the DME the same way as a regular cpap even though autopaps and other machines with more features are more expensive.  Ultimately, patient switches Resmed S8 Escape (regular cpap) for Resmed S8 Vantage (autopap) with no out of pocket 6 months later because DME doesn't want "problems."  Even the doctor apparently was/is of the view that patients pay something out of pocket for upgraded machines.  Resmed S8 Vantage (autopap) has EPR (expiratory pressure relief) but only in CPAP mode.  
1)  If one of the patient's main issues is distress breathing against pressure, how does autopap resolve that?  Isn't EPR, C-flex, Bipap, Combination thereof, or something else what will correct this?  
2)  The fundamental issue is how does a patient get a machine that they know meets their needs or a machine that anticipates changing needs and how this relates to capped rental policy/insurance?  
3)  Isn't it federally illegal for a DME company who accepts medicare assignment, meaning they have to accept the medicare approved amount and no more, to charge patients any out of pocket fees for machines with additional features?
4)  Patient has been using Resmed S8 Vantage (autopap) since 5-08 and not sleeping well.  If distress exhaling against pressure is a big problem, then would activating cpap mode with epr instead of autoset without epr resolve this?  And how does a patient know if epr should be 1,2 or 3?  
5)  If a patient wants a machine that anticipates changing needs and has auto and expiratory pressure relief and anything else, which one would it be?  Respironics or Resmed?  And how 8 months into a capped rental?  
6)  These machines are not like getting a prescription for a medication, what are the rules governing trying and getting suitable machines in relation to capped rental policies? (medicare has 13 month capped rental policy and thereafter patient owns the machine and cannot have a new one for 5 years)
Sorry for the longwindedness but this can be very complicated.  Anyone can answer with the number followed by answers and by all means any additional insights.
Thank you in advance for your time

What are the pressure settings on your Resmed S8 AutoSet Vantage? There should be a pressure range: a minimum pressure and a maximum pressure. I assume the pressure range is still the 5 cms to 12 cms you mentioned? But then you also mentioned that the 2 weeks loan of the autoPAP indicated a set pressure of 10 cms. Yet you had originally been scripted 8 cms of pressure on the Escape.

1] We don't know if your problem is just exhalaltion. If it is Resmed's EPR provides 1 cm, 2 cms or 3 cms of pressure relief for exhalation. Access to the EPR function should be allowed for the patient to change it to whichever setting is most comfortable; 1, 2 or 3.

2] Firmness and diplomacy is what is needed to get a fully data capable CPAP rather than a bare bone, compliance data only CPAP - or refusing to do business w/the DME supplier and going to another. Most all local DME suppliers contract w/Medicare as it is the backbone of their entire business. Of course, if you have a secondary insurance to pick up your copay then you need to use those local DME suppliers your secondary is contracted w/if you want them to pick up your copay.

3] You were very fortunate your doctor stood up for you and got you the Resmed S8 AutoSet Vantage. It is my understanding that DME suppliers who contract w/Medicare are not supposed to charge the patient above the 20% Medicare copay for equipment - but - it MIGHT be that they can charge you a 20% copay on the BILLED amount, rather than on the ALLOWED amount for an autoPAP. Only Medicare or CMS could correctly answer that question.

4] You would not be the only one who doesn't do as well in auto mode w/an autoPAP as in straight CPAP mode. Some of us are just more sensitive to pressure changes than others. Personally, I would set my Vantage to CPAP mode at 10 cms and try EPR at 1 for a week, then at 2 for a week and then at 3 for a week and I wouldn't make any other changes, not even a mask change during that time.

But then, keep in mind, I am NOT a medical professional, just an xPAP patient like yourself.

5] Eight months into the 13 month Medicare capped rental and having been able to exchange a starting Resmed S8 Escape for a Resmed S8 AutoSet Vantage I would resign myself to being grateful I had the Vantage and let sleeping dogs lie.

6. Not being eligible for another xPAP for 5 years is NOT set in stone. And there are NO GUARANTEES that in 5 years Medicare would be willing to provide a new xPAP if your current xPAP was still working. Heck, quite a few of these xPAPs are still going strong and well after 10 and 12 years of faithful use.

If problems continue and you "fail" CPAP therapy, there are conditions that warrant stepping up to a bi-level or other. For instance, I have COPD. After 19 months on a Resmed S8 Elite (and a Resmed S8 AutoSet Vantage I self-purchased) my sleep doctor brought me back in for a bi-level titration and I was put on the new Resmed VPAP Auto bi-level this past March which Medicare and my secondary are paying for.

The only two bi-levels I was willing to consider was this new Resmed VPAP Auto or the Respironics pre-M series Bi-PAP Auto w/Bi-Flex. My sleep doctor ordered the Resmed since it wouldn't be necessary to also get a new integrated humidifier as it would had he ordered the Respironics.

Which is the better device? Six of one, half dozen of the other for most of us. For some few, the algorhythm of one manufacturer may be more comfortable than that of another manufacturer.


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Some people are like Slinkies... Not really good for anything, but they still bring a smile to your face when you push them down a flight of stairs.
Resmed VPAP Auto. Humidaire 3i, Simplicity & Micro masks, ResScan 3.4, S8 ResLink, Embla oximeter.

I think CrohnieToo is right about Medicare although I was on CPAP for about 3 to 4 months and was switched to BiPAP and 12 to 13 months later switched to VPAP, and in that 17 month period I had 6 sleep studies, I have Medicare disability and TriCare, Medicare does the 80%, TriCare does the 20%. Anyway I have never had to pay a cent out of my own pocket! I am not exactly sure how that works, but I do think CrohnieToo  has it right! I do know when the CPAP and BiPAP wasn't working I was in the Doctors office letting him know that it wasn't, Allot of my sleep studies was for titration changes! I am sure that is why my DME ordered my AdaptSV because I had the TriCare coverage, because the owner told me most people couldn't afford to pay the other 20% for my machine, but they knew with my coverage there would be no problem!
       I might also note on CPAP I had a heck of a time with exhaling and I was at my DME every other day complaining about everything! they were calling the Doc, finally the Doc ordered another sleep study for BiPAP. It was at that study they changed me from OSA to  Complex Sleep Apnea, and said that was my problem all along.???