Anderson5420's OSCAR Data

[anderson5420]

Follow-up at sleep clinic is still a bit away (April 16), but I had a long telephone conversation with the PA late last week. The long and the short of it was that she said it will take up to three months to determine that my high CA numbers are not "therapy-induced central apnea." That is a real thing. Mumbo-jumbo about "American Board" of this or that criteria for ASV, they can't prescribe without meeting criteria, insurance won't pay. etc., etc.  At least she is following the data that my AirSense 10 Autoset sends to Apria every morning, and is totally aware of the numbers that I have been posting.  She also suggested we might try some different pressure settings but so far has not given me any specifics about what she is thinking. I am a little less than one month into therapy, so three months will be two more months, or around June 5th.  So no joy. 

Today:

AHI 12.85
OA0.47
CA 10.84
UA 0.59
H 0.94
RERA o
CSR 13.06%
LL 8.79%

[SarcasticDave94]

Treatment emergent or therapy induced CA equals the same. The conversation with a PA isn't equal a doctor. If they're really concerned with insurance criteria why aren't you conversing with a doc? My memory failed to recall but there must have been some diagnostic CA data that indicates CA were existent then. If so, this is NOT treatment emergent or therapy induced. Tell them to wise up. It's not going to get better and I'd keep complaining. Get your ASV. Then fire them for incompetence.

[Sleeprider]

The point is, you should not let the PA tell you your DIAGNOSIS is contingent on approval of insurance. You should be diagnosed NOW with complex or predominately central apnea. That needs to be on your medical record. Insurance can decline ASV until you fail CPAP or BPAP by whatever criteria the insurance company may impose, but your DOCTOR must identify your medical needs and prescribe accordingly. Then if insurance dpenies it, he must help you appeal. I don't know what kind of backwards world your PA lives in, but he is charged with your health, not the insurance company's happiness. Don't accept this horse sh*t laying down! Complain to the doctor that he is there for your health, not to tell you insurance policies.

[anderson5420]

Treatment emergent or therapy induced CA equals the same. The conversation with a PA isn't equal a doctor. If they're really concerned with insurance criteria why aren't you conversing with a doc? My memory failed to recall but there must have been some diagnostic CA data that indicates CA were existent then. If so, this is NOT treatment emergent or therapy induced. Tell them to wise up. It's not going to get better and I'd keep complaining. Get your ASV. Then fire them for incompetence.

Understood. Here is the email I just sent to the PA.

* * *

Meralee,

Could you please request that Dr. Webb be present at my follow-up on April 16? I don't mean to be a problem child but this is the first time I have had a doctor whom I have not even met in the course of treatment.

The data from March 5 to today that show virtually all central apnea events by a huge preponderance could be "treatment-emergent" or "treatment-induced." The problem I am having with that is the two studies prior to my even beginning treatment. The Full Night Polysomnogram had 33 apeneas, of which 25 were obstructive but 8 were central. In the Titration Study, weeks before I received my APAP and started using it, the situation was reversed. There were 14 apneas, of which only 3 were obstructive and 11 were central. That does not look like treatment-induced to me. That looks like central apnea was present at the time of the studies and pre-dated the start of treatment. So I would appreciate some help in understanding this.

Also. shouldn't the doctor discount insurance considerations? It seems to me my doctor should first be focused on my health, not insurance criteria. I would hope, if Dr. Webb concluded on examining everything that my central apnea pre-existed therapy, he would assist in the appeal of any insurance denial on my behalf. My hypoxemia diagnosed at Peace Health after the knee surgery together with concerns Dr. Steel has expressed concerning my cardiac situation elevate the importance of this in mind.

Anyway, thanks for your consideration.

Pat Anderson

[SarcasticDave94]

OK that passes for me. Hope you get through to these knuckleheads that you're the patient and they aren't treating you. Good job, Pat.

Trust me, you have to light fires under these people to treat you as you ought to be. Keep us informed OK?

[Sleeprider]

You should be a diplomat. Well done!

[sheepless]

playing devil's advocate maybe but I think it's premature to conclude you need asv. 25 oa to 8 ca does not cry out for a diagnosis of central apnea, or even mixed apnea, although a stronger case can be made for the latter and you'd still need asv for it. 

but the increase in ca after apap may very well be treatment induced so it isn't surprising they want you to wait 90 days to see if they abate. and if they do subside in similar proportion to your psg results, you would likely be fine with the apap. not saying the chances are great, but sufficient to make sense of their reasoning.

if you want the doc/pa's participation and insurance to pay, you gotta jump through their hoops, as ridiculous as they seem (and as much as they annoy us all). otherwise, do like I and many others have done and buy an asv from a private seller. 

but I do wish you luck with your email. it seems in this business we have to complain loudly and frequently to get the attention we deserve and pay for.

[Sleeprider]

I have seen CPAP clear up central apnea events, and yet, it is beyond the odds that results like we see in this thread turn into comfortable sleep and efficacy. If I was to pick at the current therapy for something to fix, it might be the leaks. The consistency of CA in therapy, and their presence in the diagnostic study, are unlikely to be changed by waiting, especially with the periodic breathing and other indicators of complex apnea. The criteria of the PA as suggested by the AASA is nothing more than a concession to insurance. All that is needed is a new titration test that includes attempts CPAP therapy, bilevel and ASV, and the case can be made very quickly. Scheduling that ASV inclusive titration is the next step.

[anderson5420]

I have seen CPAP clear up central apnea events, and yet, it is beyond the odds that results like we see in this thread turn into comfortable sleep and efficacy.  If I was to pick at the current therapy for something to fix, it might be the leaks. The consistency of CA in therapy, and their presence in the diagnostic study, are unlikely to be changed by waiting, especially with the periodic breathing and other indicators of complex apnea.  The criteria of the PA as suggested by the AASA is nothing more than a concession to insurance.  All that is needed is a new titration test that includes attempts CPAP therapy, bilevel and ASV, and the case can be made  very quickly.  Scheduling that ASV inclusive titration is the next step.

Yes, the reply mentions another titration study tht includes BIPAP and ASV, not sure what she means by "IF the numbers indicate qualification for ASV."  What do you suggest I reply to that?



Hello Pat,
I have  submitted order for your CPAP to be changed to a fixed pressure of 14.6.  I do not know if this will solve any of your current concerns about the AHI, but it is a try to see if the OSA will remain well managed, and allow the CSA to stabilize.
Please keep in mind, that if there is treatment emergent central apnea  (TECSA)  it may take weeks to months to know if it will stabilize.  In the meantime,  the current numbers are not concerning.  HOWEVER, it might be good for you, if we schedule another dedicated titration study, and consider BiPAP,  then  ASV,  IF the numbers indicate qualification for ASV.  Also, do you have any word back on the results of an echocardiogram?
 
Meralee 

[Sleeprider]

That's progress. The reply should request that the PA expedite making arrangements for the titration study for BiPAP and ASV as scheduling may be several months out. This appointment can always be cancelled in the event your CA unexpectedly self-corrects. This will ensure that once the decision is made to purse a higher level of therapy, it can be evaluated in a timely way. This approach gives you a time-frame you can work with, and makes you a more proactive participant, rather then just drifting through an undefined waiting period, then waiting weeks or months for the next step to be scheduled and approved. I have observed that waiting times for sleep study evaluations like this are quite long with the COVID delaying studies for months and causing a backlog. Think of it like a reservation that can be cancelled if the unexpected happens.