Bilevel machine - advice needed

[LookingForward]

After my sleep study in June 2018, I know that I'll be needing a BiLevel machine. My choice is ResMed AirCurve 10.

Although I would like the Auto since it can also be set to standard, I asked my doctor about it and he said absolutely no. I tried to tell him that online, the cost for the standard and auto are the same ($1,726.00). That it can be set to standard to start then switched to auto if needed. That the insurance code is the exact same for both models.

My doctor got upset and told me that I was wrong and the Auto machines are very intricate and way more expensive. He said I don't need it, my sleep study was only done under the standard setting and he would not write the script for it.

He was willing to go with the standard ResMed AirCurve 10 though. I did gently tell him that if would be willing to look it up himself that he would find that the price I quoted for both machines was the same and the insurance code number is the same. But even as we were talking he said he send the script to Lincare as and it was for the standard.

That was a week and a half ago. I still haven't heard from Lincare. I know it takes time for insurance approval so I'm expecting a call this week.

So I don't know if the battle is completely lost to get the Auto and set it at first as a standard setting or not or if I should also try the same logic on Lincare and see if they will go with Auto?

My sleep study had various issues. Because of back pain I had asked my doctor for a script to help with the pain while laying flat so I could make it through the study. I took it and I did complete the study without pain but I didn't actually fall into anything more than a surface level sleep for the first several hours. When I finally did fall asleep, I never made it to REM sleep. Plus I had a cold so my nose and sinuses were congested. Also the newness of having the mask on my face made for a poor night's sleep. I'm still trying to figure out what to do about the extreme dry mouth issue that kept waking me up over and over as well. All to say that it's quite possible that my pressure level may change at home where I'm more comfortable. Hopefully the pressure won't need to be as high.

Anyway, my pressure during the study showed that I need 18 to 12. When I had a sleep study two years ago my pressure was 11 to 5. That's a pretty big jump for 2 years. At that time I did get a machine but there were lots of negative issues and I ended up returning it. So I'm a second time newbie.

I pointed all that out to the doctor. He did say that it was obvious that I had done my research but I wasn't tested for Auto, they are more expensive and he would not prescribe it.

So I guess my question is, am I still stuck with the standard BiLevel or will the DME listen to those reasons since the insurance code is exactly the same? I'm guessing not since they are in this for profit.

I need to figure out the total cost when Lincare calls. Ask what the cost will be for the rental each month and the overall cost since I have to pay 20% plus the rental cost, I think.

My husband would rather see me use in-network and use up the deductible in case other health issues come up. But if I can show him that it would be overall cheaper to buy online and pay the 30% out of network cost, maybe he will be okay with it.

Also I asked my doctor for a copy of the prescription for the machine and the supplies so that I could see it myself and possibly switch to an online provider and so far that hasn't happened either. He said that I needed the local DME to help me with the machine and all the supplies so the prescription went there. He said that I'll also need the DME if the machine needs repaired or if after a time I need to change machines, they will have to take it back and switch it.

I'll need to ask again for the prescription though. I would like the choice to buy a mask online if they are on sale, so I can try various ones.

When I initially called Lincare, I was told that I would have one month to switch masks to find the right one. After that I will always get the same mask. I would be put on auto shipment every 6 months of a new mask and all the other supplies they felt I needed.

I don't think that is right either. I would like the option to try various current masks and try the new masks as others come out in the future. I also don't think I need to just get a new hose or other supplies at their discretion just so they can charge my insurance every 6 months. Am I wrong about that?

Also, I think the machine comes with a 2GB SD card. Is that big enough or should I get a bigger one and start with that? I've only glanced at SleepyHead but plan on learning to use it and post images from it. I'm just working on getting educated on the right machine, mask and equipment first.

Thanks ahead of time for your help. Sorry for such a long post with so many questions. I've just really enjoyed this thread and wanted to ask my questions here.

I am also posting on a different forum. Hopefully it's okay to get various opinions from various sources. There are three forums that I really enjoy. I'm learning so much. All of you on the various forums are so helpful.

[Walla Walla]

The DME has to follow the Doctor's Prescription or they could lose their license. I think you'll find the DME's overcharge for everything and that depending on your insurance you may save a lot of money just buying the machine and supplies yourself.

[Aonar Maoir]

Anyway, my pressure during the study showed that I need 18 to 12. When I had a sleep study two years ago my pressure was 11 to 5. That's a pretty big jump for 2 years. At that time I did get a machine but there were lots of negative issues and I ended up returning it. So I'm a second time newbie.
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You might ask your Sleep Doctors office for your titration PSG (polysomnograph), and look at how long you were held at each pressure setting.  They may have adjusted pressures upward on the basis of the estimated AHI (average hypopneas per hour).  Look for trend dips in the AHI numbers.  A more preferable pressure setting may lie therein.

An average hypopnea per hour statistic for a given can be a huge over exaggeration if you were there for just 10 min, and your tendency is (like mine) to have an event or two early on and then settle down to nil.  2 events/10 min = 12 events /60 min = AHI of 12 when it may have been actually 2, and so on. The reason may have been due to a sleep prescription given in a case of mixed apnea. 

I know of a person who was  titrated to 9 cm H2O BEYOND their ideal pressure, 
because of this, which was intolerable. They could not keep the mask on for more than  an hour or two at 21 cm H2O.  The reason may have been sleep medication interfering with mixed apnea.

Check around to see how others have dealt with pressure issues.  
It is possible that a standard Aircurve S10 can be run in different modes 
such as Bipap and ST.  A setup manual online might be able to be found
online which would say.

The $1749 Aircurves are either unsold older stock, technically till new...
or are perhaps well reconditioned. In any case, getting Medicare or an insurance company to pay fr something NOT from a DME is difficult. 

If course, check with your Doctor on whatever you do.

Bon Chance

[Sleeprider]

Your doctor is determined that you shall use his fixed settings. All the excuses are BS. You either need a doctor that will work with your, or you will have to deal with a doctor that works you over. Under federal HIPAA law, the prescription and copies of any sleep studies are your to use as you see fit. https://www.hhs.gov/hipaa/for-individual...index.html

[LookingForward]

You might ask your Sleep Doctors office for your titration PSG (polysomnograph), and look at how long you were held at each pressure setting.  They may have adjusted pressures upward on the basis of the estimated AHI (average hypopneas per hour).  Look for trend dips in the AHI numbers.  A more preferable pressure setting may lie therein.



***I agree that I need to request a copy of the study. I do know from seeing the raw data at the doctor appointment that I was on CPAP the first half of the night. I didn't go any deeper than a very light sleep or not sleeping. There were lots of events during that time. In the middle of the night I was switched to BiLevel mode. I did sleep deeper but never went into REM sleep. The doctor commented about all that. I also saw on the left side of the screen where the pressures of 17 to 10, 18 to 12 and 19 to (something, don't remember) was used. All of that time showed no events. So the doctor said that the middle pressure that was tried was my optimal pressure.




I know of a person who was  titrated to 9 cm H2O BEYOND their ideal pressure, 
because of this, which was intolerable. They could not keep the mask on for more than  an hour or two at 21 cm H2O.  The reason may have been sleep medication interfering with mixed apnea.

**** I'm hoping that when I get the machine and learn at least enough about SleepyHead to post the pictures that the knowledgeable ones on here can help me make adjustments as needed. I'm still now convinced that I need a pressure so high continually. 



Check around to see how others have dealt with pressure issues.  
It is possible that a standard Aircurve S10 can be run in different modes 
such as Bipap and ST.  A setup manual online might be able to be found
online which would say.


*****I've looked enough to know that the Standard BiPap is data capable but can't be switched to Auto, ST or ASV. The Auto can be switched from Standard to Auto. The ST can be switched from Standard to Timed (Back Up Rate) but not Auto. So the Auto would be ideal right now, I think.



The $1749 Aircurves are either unsold older stock, technically till new...
or are perhaps well reconditioned. In any case, getting Medicare or an insurance company to pay fr something NOT from a DME is difficult. 


****** As far as the $1,726.00, is the current listed price for brand new for both the ResMed AirCurve 10 Standard
and the ResMed AirCurve 10 AUTO. It's listed online for that price at [commercial links to DME websites removed, please refer to CPAP Supplier List for instructions on how to insert DME links] and it is the newest model number for the ResMed BiLevel. My insurance said that I have the choice to buy from any of those three as out of network and submit the forms myself.



Thanks so much for the input.

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[LookingForward]

Your doctor is determined that you shall use his fixed settings. All the excuses are BS. You either need a doctor that will work with your, or you will have to deal with a doctor that works you over.  Under federal HIPAA law, the prescription and copies of any sleep studies are your to use as you see fit.  https://www.hhs.gov/hipaa/for-individual...index.html

For the most part, my doctor has been a nice guy. He's old enough to retire though so maybe very old school. I surprised him with the knowledge that I learned on here. He wasn't expecting that at all. But he only knows that DME are hard to deal with but he feels they are the only way to go. He didn't believe me that the machines cost the same but didn't double check my facts either. He assumed that I didn't know. 

I do agree though that he needs to provide a copy of the prescription and study. I also have pulmonary function testing and want those results as well.

After calling [commercial link removed, instead, go to Supplier #1], they said as long as I have a prescription for a Bilevel that shows the two pressure settings, since the insurance code is the same that I can choose either the Standard or Auto. 

I'm going to tell Lincare the same and see what they say. Tomorrow will be 13 days since the script was sent to Lincare. I'm not sure how much more time I should give them before I call them myself.

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[Sleeprider]

Fixed pressure bilevel machines like the Resmed Aircurve 10 VPAP-S are very good machines and will probably work out fine, but I think you will find the Vauto just a bit better. The auto-titrating functionality is useful to learn what range provides the most comfortable and effective therapy, but even with the Vauto, I consider proper titration to mean that pressure changes withing a very limited range. In my case, the EPAP is set high enough that the pressure will only change by up to 3-cm over the course of a night This avoids sleep disruption by keeping pressure changes in an effective range, and avoiding wide swings. I do think our needs change through the night, and over time, pressure need may drift due to sleep stage, health, weight, and environment. You may have some drinks, change altitude, have a cold or allergy, or maybe you just sleep poorly. Just like CPAP, and auto-adjusting machine set to a narrow range makes the necessary changes as your needs change.

It's fair to say, some people get better results with fixed pressure, and the Vauto can provide that; but I think many more of us do better with the flexibility of a machine that can change pressure a bit, while maintaining pressure support through the range. The most disappointing thing about your doctor's inflexible attitude, is that a clinical titration is just a snapshot of what worked at that time for the sleep technician. This snapshot may be as little as 30 minutes or as long as 2-hours and it is rare that it is as optimized as what can be achieved with Auto adjusting machines over the long-term. In some cases, titration results can be way-off.

[LookingForward]

I may have won this battle after all!

I called my insurance today to ask more questions. Basically I found out that Lincare still hasn't even sent the request for any bilevel machine to the insurance yet. So that 1-2 weeks wait for approval still hasn't started.

I then talked to my insurance about all the reasons why I wanted the Auto instead of Standard and asked them if it mattered to them since the insurance code was the same, therefore the amount they would pay to Lincare for either machine would be the same. The insurance lady fully agreed with me. She said there was no reason not to request an Auto and that the one code does include both machines. She said that under the circumstances she would do the same thing!

So I called Lincare. I first asked about getting my prescription sent to the insurance then continued on about getting the Auto instead of Standard. I told the lady all I learned about the codes and how they are paid. Also that I knew that the insurance agreed to pay the exact same amount to them for both machines. I quoted the current online price for both machines and knew they were the same. I told her I knew I could set an auto as standard but then have the right machine as my pressure needs changed. Basically I told her all that I've learned about picking out my machine, thanks to all of you!

There was a pause on the phone and a bit of a gasp. She asked me how I learned all that? Did I have prior experience with all of this to know everything I told her? She said they don't have clients requesting a certain machine, I was their first.

She finally agreed that they only send in a request for that code to the insurance not a specific machine. So when they get that insurance approval, I was right and it did actually cover both machines.

I asked her to read the prescription to me and she said it only said a bilevel machine with the pressure of 18 to 12 and a large size full face DreamWear mask.

She said the doctor didn't specify standard or auto only the correct pressure setting.

I then told her that I was specifically requesting a ResMed AirCurve 10 VAUTO with heated humidifier. Also my face is small and I didn't want the Dreamwear mask. Instead I wanted to try the Amara View Full Face.

She was surprised again that I was so specific. She agreed that it was within my rights to get that based on the prescription! She said she would specifically order that machine and mask. She said it may take longer but she would put in the request for it.

I don't have anything yet, only the insurance in full agreement and Lincare at least verbally agreeing.

Lincare even called me back a few hours later to ask one more question so that she could go ahead and place the order for the Auto machine!

I can't thank all of you enough for the information you have provided. I was educated about all this because of each of you!

[Walla Walla]

[holden4th]

Knowledge is power.