[CPAP] How often is sleep study required?

[SlightlySleepy]

I'm fairly new here so please forgive if this has been discussed in depth before. I have read the thread regarding the pro's and con's of self adjusting pressures, but that is not my question. My question is: Does anyone ever get cured of Sleep Apnea? If not, how often is a repeat sleep study really required if one is planning to purchase the Resmed S9 Autoset?

Here's my story. Keep in mind I am a physician (not sleep specialist and not currently in clinical practice) and I am not obese. I might or might not benefit from nasal or maxillary advancement surgery but after consulting with the best of the best, decided against it. When doctors think of having surgery they run, not walk away. So until and if my CPAP stops being effective, CPAP is for me.

I've been doing OK until recently I have awakened about 2am with palpitations unrelated to any dream activity etc. My current machine is so old it has no logging abilities, so after learning about the newer machines I have done due diligence and decided to go with the Resmed S9 Autoset. Since we pay good money for good insurance (PPO from a major carrier) I thought it would not be a difficult thing to get a new machine (my last machine was purchased in 2006).

After spending over 5 hours spread over two days on the phone with my DME provider, Insurance company, Sleep specialist (whom I have not seen since 2006) and alternate DME providers (including internet providers) I am becoming very frustrated. I am coming close to just plunking down $1200 and being done with it. My time is too valuable to me to waste on this nonsense. But the principle of this bugs me -- I've paid premiums, why can't I get a new machine? Here's the deal as I understand it:

1) My insurance carrier contracts with certain vendors. If I purchase from one of them, they will pay 90% of the contracted rate and I pay 10%. I cannot be billed for any additional cost of the equipment.

2) If I go to a non-contracted DME provider, insurance will only pay 70% of 'reasonable & customary' but no one is able to tell me what that is. Bottom line, it will cost more to go with a non-contracted provider, even if the device is much cheaper (say $853 on the internet vs. $1100 for the identical device from my current DME provider).

3) My DME provider(s) say that they cannot tell me how much their contracted rate with my insurance carrier is without doing a full requisition which takes about one week. And according to my Doctor's office, the insurance companies are now following Medicare guidelines and requiring a sleep study every 4 years.

Calling a new DME provider would require a new prescription within 30 days of the date of purchase of the new equipment. In any case, this would would require many days because they are about a week behind on fulfilling orders. They can't even tell how much the machine would cost even knowing the name of my insurance carrier "because there are 1000 different versions of that carrier"....what? New price for every employee in the company?

In either case, they too are very busy and could not even promise to get a new machine authorized for at least 3 days even though they admit they have them in stock. I will probably need a new sleep study and definitely a new prescription less than 30 days old.

4) A sleep study costs about $4000 according to my doctor's office. I do not know what the contracted rate with the insurance company.

5) I contacted an internet provider from the DME suppliers list and they said that CPAP prescriptions can be good indefinitely, depending on how they are written.

I asked if anyone ever got cured of sleep apnea without surgery and so far no one has been able to say so.

I sleep terribly in those sleep labs. I've had 4 sleep studies. Three of them at a nationally renowned sleep study specialty center which on one occasion even did the esophageal pressure monitoring. They all say the same thing - obstructive sleep apnea or upper airway disease. Old code 780.53 (I understand the new ICD code is 300's something).

The last was in 2006 and lowest O2 sat was 94, Respiratory Disturbance Index was 16.4 (NOTE: Sleep efficiency was low at 36.6%, Total sleep time was only 194 minutes or just over 3 hours due to sleep onset insomnia due to surroundings---I normally sleep like a baby and cannot be awakened). No central apnea but 53 obstructive hypopneas (16.4 index) mean duration 16.2, longest 32.5, 10 in REM, 43 in NREM sleep)

A previous set of two studies over 10 years ago was similar, 94% minimum oxygen sat, max negative Pes was -22cm H20 to -8cm H20, Respiratory Disturbance Index was 6.3 to improved to 2.1 with 6cm H20 CPAP with poor sleep efficiency (40.2) dx Obstructive sleep apnea with poor sleep efficiency. 1 central apnea episode, 3 hypopneas.

My initial (and current) CPAP pressure is low (6 cm H20) and I suspect I may be having some breakthrough obstructive episodes.

Frankly, if the insurance company wants me to have another $4000 sleep study I'm fine with that, but for intellectual curiousity, I'm wondering whether it is really medically necessary and how dangerous it would be for me to just get an S9 first to see what it reads out before doing another study. In other words, does a sleep study really offer all that much benefit that a logging CPAP machine cannot, especially after factoring in how lousy my sleep is in those labs?

Meanwhile, in my early 50's, these palpitation episodes leave me feeling tired in the morning with chest achiness. I don't think it's angina (I don't have any risk factors, excellent cholesterol, vegan, etc, but it does make me think I don't want to wait forever to find out what is going on. Going to the ER would be thousands.

[JumpStart]

Hi, SlightlySleepy. You indicated that each of your past sleep studies confirmed OSA. So my first question is, have you lost a considerable amount of weight since the last study which confirmed OSA? I know you said you were currently not overweight. If the answer is "no", I would say that you could safely acquire a new auto device and begin using it *around* the pressures you previously had titrated, but, unlike you, I AM NOT AN MD. As to prescriptions for machines - it doesn't take a specialist to prescribe a CPAP machine, but I am unfamiliar with medical guidelines where a physician prescribes either for himself or his family. Have friends who do it for medication, but this may be different. You would be most knowledgeable about that, but if it is OK, or even if it just works, your own script should be adequate to meet all legal requirements. I suspect it would be OK all online suppliers, and even one of them doesn't require a Rx at all, according to a recent post in this forum.

That said, a sleep doc's participation would be the best first choice to answer your question. Does your doc have any hesitation about issuing a script? Or about you doing a home study with an auto titrating machine?

In passing, I would note that your OSA, if the figures then are still the same now, is low, so that is a good thing. And I know others will provide info you may have already read on this site about your DME, what they are paid for the machine, your insurance company, etc. It is good info, so read it carefully. It will help you get what you need.

Also, if your doc will prescribe a machine, have him prescribe the machine you want, and indicate "dispense as written". That will alleviate a lot of insurance and DME issues.

[PaulaO2]

If you were morbidly obese, there *might* be a small chance of a "cure" since your apnea appears to be on the mild to moderate side. An O2 of 94% is rather good. People who lose massive amounts of weight often have their pressures lowered but I've not heard of anyone able to drop the machine altogether.

However, since you are not obese and are in relatively good health, then it is likely you cannot be "cured".

Racing heart after an event or set of events is common. I know that's one of my symptoms. Your body kicks in the fight or flight response harder and harder until you wake up and breathe. Heart rate increases not only from this but from the general stress of not breathing.

Supplier #2 on the suppliers list sells slightly used and new machines at a very good cost. If you decide to go out of pocket, they're a good resource.

The DMEs, regardless of insurance, as far as I know, get paid the same amount for whatever machine. Let's say $1500. So a bottom of the barrel machine at $500 gets them $1000 profit. A top of the line at close to $2000 is money away and they don't like that. Some insurance may have different policies of how much they will pay.

The Medicare rule of a sleep test every 4 yrs must be new. I've been a hose head for...wow, 9 yrs? 10? Anyway, I had the initial test and that was that. Four or so years ago, I was given an oximeter to wear overnight and they raised my pressure following that. So they had their chance then to make me take a sleep test. I was very ill (bp was extremely high, staying around 200/150 and higher) so they had good reason to.

Insurance companies are stupid. They'd rather pay big bucks for tests to determine the problem (even if already known) because they hope you have since been "cured" and maybe you don't need the machine or medication or whatever. While if they concentrated on prevention and maintenance, they'd be saving a ton of money.

It has only been in the last few years or so that sleep docs are actually telling patients to come back and see them. I know I was not told when I was first diagnosed. I saw him the first time, had the tests (did not have split study), saw him two times after that and was not told to make an appt every year. Instead, I went a long time before I became ill. Even then, when I saw him again, he didn't stress when to see him again. He said it was a good idea.

So if you have not seen your sleep doc since 2006, it would be a good idea to see him/her. Touch base, express your concerns, then determine from there where to go and what to do.

[SlightlySleepy]

.. So my first question is, have you lost a considerable amount of weight since the last study which confirmed OSA?

Thanks, Jumpstart. I have not lost (or gained) any weight since my tests, in fact, my BMI is about 22 and I weigh at most 10 lbs more than I did in high school. I credit vegetarian (now vegan) diet (thank you T Colin Campbell) and moderate exercise, although of late that has been a bit spotty.

I totally understand that this is not a physician forum and advice here is 'for information only' etc etc legal disclaimers. As you suspected, I am simply looking for practical tips on pitfalls to avoid in the insurance dance. I have some experience with the insurance industry and let me just say that while they may not be evil, the system is not designed for customer satisfaction (unless you consider the insurance company or employer the customer, and even that is questionable) as would hopefully be the case in a true market economy where good service was rewarded with business and poor service avoided. It's more like miniature monopolies or going to the only car dealer in town who can service your Peugeot. Take it or leave it. Next!

As for self-prescribing, it should never be done for narcotics, I'm not really sure about CPAP machines although I probably could easily get away with it, the saying is "The doctor who treats himself has a fool for a patient and a fool for a doctor". This is not necessarily due to lack of intelligence, but lack of perspective and perhaps currency in the particular field of treatment (seeing the trees but missing the forest etc) However, I am coming to believe more and more strongly in crowd sourcing of information such as this forum provides. Although my sleep apnea is mild, I know it is real because CPAP stopped the night time palpitations (awakening with heart pounding) for several years. Since it only came back recently, I suspect the cause may be related.

I also have intermittent chronic fatigue syndrom (CFS) and have found very valuable information on user forums (google Dr. Lerner and Dr. Montoya (see also YouTube of Dr. Montoya) if you have CFS).

Thyroid and psych check out find so the best I can do is optimize all known problems, one of which is this sleep apnea issue, but obviously I don't like thinking about it more than I have to (I only recently discovered logging machines and software).

[PaulaO2]

The worst case scenario with self-titration using a CPAP (or APAP or whateverPAP) is too high a pressure can cause central apnea events which can make you think you need to raise it more since you aren't sleeping that great.

The good thing with an APAP is you set the lower number to be a notch or two below your prescribed pressure and the higher number a notch or two above it. So if your CPAP pressure was set to 8, then you'd set the APA to 6 - 10. The machine only uses the pressure you need. If, after a few weeks, you see that it is almost always right at 8, then you can set the APAP to CPAP and leave it at 8. Or you may see it keeps maxing out at 10 so you raise the top by one then gather another two weeks of data. Rinse, repeat.

The bad thing is to keep messing with the pressures on a nightly basis based on the previous night's results. It is better to gather data over a number of days to find a trend. No two nights will be the same (unless you're very anal and rarely stray from your routine).

The sleep lab gets away with setting the treatment pressure because they've got a LOT more data they are looking at. Body movement, pulse rate, O2 levels, eye movement, etc etc. APAPs can only tell you the pressure it used and, depending on the machine, what kind of events you experienced. That's why self-titration should be done over time.

[SlightlySleepy]

...Racing heart after an event or set of events is common. I know that's one of my symptoms. Your body kicks in the fight or flight response harder and harder until you wake up and breathe. Heart rate increases not only from this but from the general stress of not breathing. ...

Thanks Paula02 - I have read many of your other posts and value your always reasonable opinion and experience. This is exactly the kind of feedback I was hoping for.

I agree it would be great to see my sleep specialist. Sometime I feel like they want to do more sleep studies at their facility because it makes them more money for the hospital. That's why I chose to do my sleep study at a completely different hospital than the specialist, and possibly why he did not call me back for repeat visits. I did not pursue repeat visit either because waiting in his office for an hour with other patients coughing up smelly phlegm from their tracheostomies was not my idea of a good time last visit.

Interesting about supplier 2. I guess I feel a bit strange even considering used equipment (like buying from a pawn shop where the person who had it before probably needed it more than you but needed the money even more, or stole it, or worse, died due to some weird malfunction in the machine! Too bad they don't have an overstock.com for CPAP machines! ;-) Oh my, how the imagination can go overboard when thinking about such possible jinxes!

I have good insurance, and probably it will probably cover the internet vendor machine at 70% but only of reasonable and customary so there is a significant potential for makeup billing. Also, the out of pocket max increases to $6000 for non-contracted DME vendors.

[PollCat]

Interesting observations by my colleagues. My experience is somewhat different; I saw a sleep doc every year from 1995 to 2006, then every 18 months since then. I've had two sleep studies, the original one and another in 2008 - basically nothing had changed, though the doc said I could lower my pressure to 13 (from 15) if I wanted to.

When I realized that my machine was six years old, I asked the doc for a script for a new machine. Since he is the head of the county hospital's sleep center, I sought his recommendations for a 'good' machine. His recommendations were the S9 Autoset and the Respironics PR One System. While there was quite a price difference between these two machines, I tried them both and paid for the S9 out of my pocket (Medicare and the insurance company have yet to reimburse me anything for the machine).

If you sleep terribly at the sleep center, you should request the "little red pill". It'll knock you out quickly and keep you asleep for six to eight hours.

I've always heard that doctors make the worst patients!

[SlightlySleepy]

...I've always heard that doctors make the worst patients!

Thanks! Interesting that despite seeing your specialist regularly, you still don't get reimbursed. I assume you are either independently wealthy or someone else is making your monthly ($799/month each for us if you count employer contribution) medical insurance premiums! I would be hopping mad if my insurance carrier did not cough up some dough for my CPAP machine! We are the customer, never forget it, no matter how hard the medical system tries to hammer us down into gown wearing 'compliant' sheep!

There is some truth to the saying about doctor's making lousy patients, but not as much as you might think. What truth there is comes from at least 4 major causes:
1) Doctors are incredibly busy and forget to take care of themselves as they should, often because doing so is not compensated otherwise
2) Doctors know the risks of medical interventions and shy away from them as long as possible believing that 'if it get's bad enough, I'll know what to do', which is sometimes too late
3) Doctors, once they do decide to get medical help, don't just nod their head and take anyone's word for anything without good logical reason, they insist on the best, often second opinions from well known university researchers, etc.
4) Doctors know how things are supposed to work, and being perfectionists, usually will not settle for less than best.

On the good side, doctors can easily understand terminology so it is actually easier giving them instructions; at least if the provider is competent and willing discuss options and treat them like adults.

As SuperSleeper asks, who has their own best interest at heart more than the patient? Therefore physician as patient is probably at least as interested in optimizing self-care as anyone, with perhaps a slight advantage based on knowledge of human anatomy, pathophysiology, and pharmacology and therefore hopefully able to more easily detect quackery.

[SlightlySleepy]

...The sleep lab gets away with setting the treatment pressure because they've got a LOT more data they are looking at. Body movement, pulse rate, O2 levels, eye movement, etc etc. APAPs can only tell you the pressure it used and, depending on the machine, what kind of events you experienced. That's why self-titration should be done over time.

Good point. However, the body still takes it's usual 45 minutes to go through a portion of a sleep cycle, so with only 3 hours sleep I guess I was concerned it wasn't really enough to base a year of CPAP settings on.

As for the 'red pill' -- I don't do pills. I even have to talk them out of much sedation for minor procedures otherwise my heart rate goes to 36 and I'm zoned out for the rest of the day. I question whether the sleep study is as accurate with a pill as without. Just one more confounding factor.

My CPAP has been at 6cm H20, so obviously it is very low, but enough to make a significant difference for a while, and possibly may need a bit more tweaking. I am concerned about the Central Apnea risk however, thanks for the reminder.

[PollCat]

Thanks! Interesting that despite seeing your specialist regularly, you still don't get reimbursed. I assume you are either independently wealthy or someone else is making your monthly ($799/month each for us if you count employer contribution) medical insurance premiums! I would be hopping mad if my insurance carrier did not cough up some dough for my CPAP machine!

While not wealthy (and still waiting for my full annuity payments*) I had money set aside for CPAP equipment. I gave up buying equipment locally since I usually can get the same things online for substantially less. This most recent purchase had some problems: the first two Respironics machines were so noisy that I sent them back and finally settled on the S9 (which ended up being twice the price of the others). Medicare said they had 60 days from my initial filing of my claim and returning the supplemental paperwork to reimburse me (which should be the first of May). After Medicare pays, then the insurance company is supposed to chip in something.

* - (I retired from the US Government on July 1, 2011, after working for 42+ years - 17 years with USDA/OIG and 25 years with US Customs/IA).