Feeling like I cannot breathe

[vgrando]

The respiratory therapist told me that the MD's prescription could only be used for AirCurre Vauto because he did not order "backup pressure". His order is: Bipap setting 12/8 cm with supplemental oxygen bled into BIPAP at 2L.

I am concerned because I have persistent complex apnea with mostly CAs. And the AirCurve VAuto is not the best for this issue. If Medicare pays for the AirCurve VAuto that will be OK. But if I have to pay for it, I will request The ResMed AirCurve St A.

One question. Does the Philips have more than one Bipap and does it have "back up"?

[Jay51]

Sounds like a good plan.  Your question about Philips.  Philips has several bipap machines that I am aware of.  The Dreamstation series does I think.  Also, they have a version of the ASV just like Resmed does.  The only Philips bipap machine that I am aware of that has the AVAPS is the Philips Bipap AVAPS.  Anyone can jump in here and correct me if I am wrong.  Philips machines have a "Flex" setting that operates kind of like EPR.  It reduces exhale pressure by a small number to make it easier to exhale like the Resmed EPR does.  

So, the 2 Philips machines that I know of that do have a "back up" rate (automatically will force a breath if you don't take one) are the Dreamstation bipap AutoSV and the Bipap AVAPS.  

A good step to take would be to call your Respiratory Therapist again and ask her what Philips bipap machines you can get with the script your Dr. wrote.  You can then post that here (and/or then check the specs on it online).  I would be happy to research all the Philips machines that you could get with this script so that you can make the best possible decision here.  Tell the RT about your hypoventilation and complex sleep apnea and CA's.  The RT can sometimes pull some strings to get a slightly different machine that may work better for you.  When the RT calls the Dr. with their recommendations, the Dr. usually listens to that and agrees.  If you get the RT on your side here (convince them of your hypoventilation, etc. they can make life a lot easier for you now and in the future in regards to working with your Dr. and your medical insurance I have found).  RT's have a lot of pull in these scenarios.  Try to befriend and communicate with the RT for sure.

[vgrando]

Thanks again!

My MD said I could get any machine I wanted! Unfortunately, I left home without my list of machines. 

If Medicare will pay, and that is not a given, I believe that they will only pay for the least expensive BiPap. 

I want the best machine for my situation, and I am willing to pay for it. I know that I need backup support because of my CA and low tidal volumes. Moreover, I do not like the oversight that Medicare insists on.  

Last night, I fell asleep watching TV without putting on my 02 and awoke feeling terrible. My 02 drops when I sit at rest, and my internist told me to use 02 while awake at rest. I have to get in the habit of doing it.

My MD stated that I need respiratory support at night with exercise in the daytime. I must ensure that he communicates this in his order. He told me these were just  preliminary settings, without going through another titration study, and that he would adjust them.

I am not letting some RT who knows nothing about my complex situation dictate things!

[Jay51]

You have come a long way.  Congratulations.  A machine with a back up rate would help stop your CA's only.  A "Vaps" machine would stop both your low tidal volume (and your CA's).  

At least you got the supplemental oxygen back.  That is great.  

I hope I didn't wrongly state the function and intensions of RT's.  In the DME/medical insurance/PCP (or Sleep Dr.) triangle, RT are very important.  Dr.'s listen to them and trust them.  Insurance listens to them and trusts them.  Everything starts with the Dr.'s script though, but RT has a lot of influence even over the script. If the RT found out about your hypoventilation and low tidal volume, they might call your Dr. and recommend a "Vaps" machine.  

Just saying I hope your relationship goes well with the RT at the DME.  They can be a tremendous asset.  

I hope the machine that you end up getting works out well for you.

[vgrando]

Good advice, as always! 

Thankfully, the RT and I got along fine. He did not see my chart because the Bipap order came late on Friday.  He will understand my needs better after this. After I spoke with him, I pondered what he said, and I was concerned because he told me that he rarely orders anything besides an AirCure 10 VAuto. I doubt he will advocate for me because he frequently repeated that the MD had to decide. 

I only mentioned "backup" in my earlier post because the RT told me since my MD did not add "backup"  to my order,  he must want me to have an AirCure 10 VAuto. My MD did not specify a type of BiPap.

From what I understood from your earlier post, I will ask my MD to order ResMed AirCurve10 ST-A with HumidAir & ClimateLine.

Is this a good choice?

From what I read, I think an AirCure 10 VAuto will do little to help me besides allowing me to lower EPAP settings.

[Jay51]

Yes.  The Resmed Aircurve ST (A) would be the best choice here.  It has both a back up rate that you can set at any numerical value you want to (ex:  respiratory rate of 15 or 12 or so) and this will stop your CA's.  Also, it has settings for your tidal volume; so each breath all night will be at least that much "x" numerical value tidal volume.  Say 400 or so or wherever you want to set it.  

Great thinking you did here.  I forgot that the ST (A) was actually an "Aircurve" model.  Hopefully your Dr. says this is ok.  

ClimateLine is a great choice also so you can adjust temperature anywhere you like it most comfortable. Humidair is good also IMO.  

If RT stated that the Dr. has to decide, then focus all efforts and hypoventilation information and low tidal volume documented information on your Dr.

[Jay51]

Having already been through this, the key to getting Medicare to pay for it would most likely be linking your hypoventilation with the ST (A) IVAPS that is designed specifically to treat hypoventilation.  If your Dr. understood this also, then he would be much more prone to go for the ST (A).   Once he writes the prescription for the ST (A), it would seem Medicare would cover it (since both your hypoventilation is already documented in a sleep study; and this machine has an algorithm specifically for treating hypoventilation).  

Here is the product description of the ST (A).  

Product highlights

• •
  Designed for people with respiratory conditions that affect breathing such as restrictive lung disorders, severe COPD and hypoventilation
  
• •
  Intelligent Backup Rate (iBR) maximizes your freedom to breathe spontaneously
  
• •
  Intelligent Volume-Assured Pressure Support (iVAPS) automatically adapts to changes in your sleep and breathing
  

• •
  Ramp Down feature lets you gradually reduce pressure support for a comfortable transition to spontaneous breathing
  
• •
  Fixed and adjustable alarms offer added safety
  
• •
  Indicated for pediatric use on patients weighing more than 30lbs (or 66lbs if using iVAPS)
  

Here is the Resmed website that has the specs on the ST (A).   AirCurve 10 ST A - ResMed

I have gone to Dr.'s appointments with information like this in hand to give to my Dr.'s   Everyone of them has taken the info.  I try to hit the highlights in the time I have during the appointment.

[vgrando]

Thank you!  I have done that with my MD, and my MD told me I could get the machine I wanted since I was paying for it. 

I did not realize that he had to spell out the type of BiPap in his order. I mistakenly thought with a generic BiPap; I could choose the kind of Bipap machine as I did a CPAP order.

[Jay51]

You may be correct. I don't have Medicare. I hope that you can choose any bipap machine that you want.  Medicare may operate differently than the insurance I have (BCBS).  DME's work off of codes.  A certain code from a Dr.'s script can get several different machines within that category of code.  Example: a code for a cpap.   Or a different code for a bipap.  I think there may be different codes for a regular bipap (one without a back up rate) and a code for a bipap with a back up rate.  There may even be another code for a bipap with a back up rate and an assured volume feature.  

You have this figured out.  I hope you can get the ST (A).

[Sleeprider]

Medicare and insurance pays on HCPCS code. The prescription for a bilevel with no backup rate is 0470 (Aircurve 10 S, Vauto), but a respiratory assist device like the Aircurve 10 ST, ST-A or ASV is 0471. Anyway, look up HCPCS codes and you will find the appropriate device codes for everything from masks and filters to the type of machine.