Is My Doctor Taking Me For A Ride?

[gamestar32]

Good Afternoon All,

I've been using CPAP for a few months now. It's definitely helped with my OA's, but I still struggle with CA's and either Periodic Breathing or CSR's (I'm 28 years old, in decent shape, and have no history of heart issues so PB's seem more likely). 

I spoke to my sleep doctor about this, and they got me in for a titration study last week with the intent of determining if BiPap is going to be better suited for me. My question is this: Would ASV make more sense, and are they trying to milk me for more money with their current methodology? Both the doctor and the tech told me that I wouldn't be eligible for ASV until they've ruled out if BiPap will improve my sleep. I was told that to be eligible for ASV, an additional titration study would be required as the one I did last week was purely for BiPap and BiPap ST. 

Is this standard procedure? I would think that the study for BiPap should also be able to indicate if ASV is a better fit for me, and I'm concerned they have this model in place in order to make more money off of patients. If this isn't standard and my suspicions are correct, does anyone have any advice for how I can skip over BiPap and go straight to ASV without going completely outside of insurance? Money is a little tight now and I'd like to be as efficient as possible with my spending if possible. If this is the normal procedure though, I will stay the course.

[Sleeprider]

It is possible to order a study that evaluates BiPAP and moves to ASV is central apnea is not controlled. ST is not a suitable therapy for complex or central apnea. In the interest of saving the time, inconvenience and expense of a sleep study, a doctor should make these studies as efficient as possible. Medicare has some unclear guidance on the conditions they will accept to reimburse advanced PAP, that include failing CPAP and BiPAP. Generally, we have seen ASV approved if BiPAP does not show efficacy in a sleep test. Where that gets complicated, is the consistently inconsistent nature of central apnea, makes a sleep study very questionable. It is not unusual for someone with complex apnea to be event-free for several hours during a test, and that can lead to false results that a particular pressure was show to be effective. Of course back in their own bedroom that quickly proves to be wrong.

There are several ways to go about this, and your approach might be affected by your insurance and copays. If you have very good insurance, you can afford to fail at all these machines. and finally end up on ASV. If not, it is sometimes more cost-effective to buy one off a site like DotMed, and prove efficacy through use. Lots of members here have taken that approach. At this point, your doctor is not going to budge from trialing BiPAP and waiting for you to fail before titrating ASV. Something you need to know about ASV and titration. ASV is 100% automatic. There is no titration. It either works or doesn't, and with AutoASV the machine does all the work raising EPAP to resolve obstructive apnea, and using adaptive pressure support to resolve all periodic breathing, hypopnea and central apnea. Typically individuals like yourself can use the default settings in AutoASV and experience near-zero events.

[ischua]

I have found over the years dealing with anyone in maters of my health is to speak up ask why. Ask plenty of questions and get other options (if any). Most doctors are willing to work with you. If you want ASV you could go used or rebuilt too.

[gamestar32]

Thanks for the reply Sleeprider! 

My DME has a 50% coinsurance with a fairly high MOOP that won't be getting met any time soon by my account. Based on the prices for machines I see online, it would likely be cheaper for me to just get an ASV from Dotmed rather than go through this whole song and dance of trying BIPAP first before undergoing another study/new machine.

On the subject of ASV titration, if I understand you correctly, you're saying that the only value a "titration" study for it is to see if it's effective or not since the settings aren't manipulated in the same way a CPAP, APAP, or BiPAP is? 

Are you aware of any cases where BiPAP is better suited for someone than an ASV, or is it usually the case that if BiPAP works, ASV would just be better? If that's true, I'll probably hear what my doctor has to say and jump to an ASV out of pocket if it doesn't seem promising.

[Sleeprider]

A couple additional thoughts. The ST bilevel is in the same HCPCS code as the ASV, E0471. There is no good reason not to titrate or test ASV when the physician knows you have a central or complex apnea problem, it is simply the only therapy recommended for those problems. ST is intended for COPD an pulmonary hypventilation due to disease or obesity. The Resmed Clinical Titration Guideline shows what conditions each of these devices is intended to treat, and for every titration protocol, central apnea means "move to ASV". Read this and use it as a reference in future discussions with your doctor. https://www.resmed.com/us/dam/documents/...er_eng.pdf

[gamestar32]

That's a terrific resource, thank you for sharing! Based on your summary and what I'm seeing from a quick initial glance, it sounds like BiPAP in any form is not what I need and that ASV should be the next step. I'll do a deeper dive into the titration guide in preparation for my conversation with the doctor. If I'm unable to get them to write a script for ASV then and there, I will purchase one myself through DotMed and make sure it's running default settings. I want to take care of this issue as quickly as I can and start taking my life back. 

Thank you for the quick replies! It's much appreciated.

[Sleeprider]

If you'd like to post some Oscar charts of your therapy that shows the extent of the issues you're dealing with, I'll be glad to comment. ASV is a bilevel device, but it has what we call a backup rate so it can act to ventilate in the event your spontaneous respiratory effort is not present. The ASV monitors your last 90 seconds of respiration rate and volume and uses adaptive pressure support to maintain that. The ST stands for "spontaneous-timed" It uses fixed pressures (IPAP/EPAP) and if your spontaneous effort does not trigger IPAP in a set time, the machine will do it. The problem is, that pressure support is fixed, so depending on settings, you will get perhaps 4 to 6 cm of additional pressure. Sometimes that stimulus works to cause a semi-spontaneous breath, but the ASV will use pressure support when and as needed to maintain your normal respiratory volume and rate. It can use up to 15 cm of additional pressure to cause a breath, or do nothing but minimum pressure support as needed. They are completely different. I would not be surprised to see your doctor try to prescribe ST. I have seen this literally hundreds of times, and in most cases ST is not tolerated. It feels artificial because of the abrupt on/off square-wave pressure transitions, and generally leaves many events untreated. The ASV uses the Easybreathe™ pressure transition which is similar to your Airsense 11 if you used EPR. It's more comfortable and invariably effective.

[gamestar32]

If you'd like to post some Oscar charts of your therapy that shows the extent of the issues you're dealing with, I'll be glad to comment.  

That would be great. I'm at work right now but I can post a few shots of my last few evenings with close-ups of the periodic breathing episodes. Thanks for your responsiveness. It means the world to me.

[SarcasticDave94]

Can you post your redacted of personal info sleep study in detail? It's pretty easy to view if you in fact need ASV.

Agreed ST would be pretty terrible unless you've got lung disease, sounds like you don't, so say NO to this.

My guess on the tests... Doctors love to test you because the tests cost MONEY to you and insurance. And there's zero guarantee of proper treatment after said test. The greedy answer is hmmm that test wasn't clear, let's test again.

Titration is a waste typically because doctors almost always get things wrong. Besides you're able to self titrate as long as you want after you get a machine and SD card feeding data into OSCAR. You post OSCAR usage, telling us some details in what's not great yet, uncomfortable, etc. And us Board members chat with you over coffee. Yeah OK change this setting try it and tell us how it went with a new OSCAR chart. There's your free Titration as long as you need it. 100% free in the comfort of your own personal sleep center AKA bedroom.

If you need ASV it's easy to dial in. I've done it myself. I can't use one now because I'm the Central Apnea mixed with COPD/Asthma guy.
Welcome to the farm.

[gamestar32]

I'm still waiting on the results. They like to gatekeep them in my experience but I absolutely will get my hands on a report and post it here. I'll post some of my OSCAR data later as well.  

Yeah, that sort of behavior from the doctor is what I was afraid of. Had I done more research on BiPAP prior, I would have insisted we skip this study and jump straight to ASV so as to move this process along. I'll be referencing the titration guide Sleeprider shared when I meet with the doctor and asking why the device that's listed for COPD etc. makes more sense for me, someone without it, than the machine designed for mixed apneas and periodic breathing, something I clearly show. 

If he refuses to write a script for me then I'll have to resort to the gray market for one, although I really don't love that since getting new supplies will likely be a nightmare for a while. Here's to hoping I can get him in a reasonable mood.