self titrating an ASV

[TASmart]

Here is Resmeds titration guide for the S9 series. It may have what you seek.

https://www.dropbox.com/sh/gtn5sfgutaou3...FnCWa?dl=0

[xxyzx]

Are you buying fully out of pocket, or insurance?

i am getting ready to ask insurance to pay for it
so far the lady i talked to did not want to see what the doctor wrote up
the DME fed her a line of crap that i think i got undone
then she called the sleep lab and got confused about what they had done
but sent me approval for a PSG for a CPAP

WTF!!

they gave me a bipap the first time
it failed
the doctor said so and justified it

There is no need to redo a useless test when i cant sleep at that place when they want you to.
and the environment is totally different so the results are more questionable.
Also one night is not as good as a month.

It would be cheaper to let me try the ASV at home and see how it works. 
It is possible that no machine can fix the CA and the OSA for me. 

I am getting all my ducks lined up information wise to be prepared to see their approval guy and bypass the so called service rep.

Hi xxyzx,

The PSG is usually the first overnight test, given to monitor your sleep without any CPAP machine.

You may be able to find a different sleep lab covered by your insurance which, after you show them the ASV prescription, will be able to help get an ASV titration preauthorized by your insurance.  Titrations are usually ridiculously expensive and I suggest not scheduling one unless it is preauthorized with insurance paying for it. 

You already have the prescription for an ASV machine, and if you want to pay for the machine out of pocket without help from insurance Supplier #2 on our supplier list presently has available relatively inexpensive gently used ResMed S9 Auto ASV machines for US$ 1,249 (REF# 36037).

But if you would want an insurance company to reimburse you, you would need to follow whatever rules they may have, which usually say an ASV titration is needed first to prove benefit, or else no reimbursement.

Your present bilevel settings are 11/14, which I suppose means 11 while exhaling and 14 while inhaling. This implies you need up to 11 while exhaling in order to prevent most obstructive events, and 3 higher when inhaling in order to avoid Flow Limitations.

The ResMed ASV machines have only a few settings and are largely self-titrating.  Settings of 9 for Min EPAP and 13 for Max EPAP would be two lower and two higher than your present EPAP setting of 11. A setting for Min Pressure Support of 2 or 3 would be around the same as your present PS of 3.  The Max PS setting must be at least 5 higher than the Min PS setting, and I would suggest using a Max PS setting of 10 or higher (but higher than 10 is usually not needed unless you have COPD or another unusual lung condition).

Take care,
--- Vaughn

not going to a sleep lab ever again
i can not sleep at the hours they want me to sleep for their convenience

i had a home test that showed some apnea problems
i had a titration test in a sleep lab taht was a torture event
in lab 11 hours got 3 hours sleep from 6 to 9 am when they woke me up as 3 hours of data was the min they needed

the bleep insurance authorised another PSG for a CPAP
when i had failed cpap the first time and got a bipap
the bipap failed in real life and the doctor said so

the doctor wrote an Rx for an ASV and a justification
the insurance service rep refused to even look at his write up

i remember saying i could not exhale at 10 when they were doing one pressure
i ended up with 11/14  which was their best guess for what worked considering the short sleep time

thanks for your tips
i am not going to buy anything

i will see the official approval folks 
and then appeal if necessary

a month at home would be cheaper and more meaningful than another titration test
which i doubt would work considering i cant sleep in those labs when they want me to

auto titration has been around for 20 years
sleep labs just want to suck money out of my wallet and the insurance company

[Sleeprider]

XXyzx, I share your sentiments on sleep labs and clinical titrations. I think the only way you will convince your doctor and insurance to authorize the ASV is to start with with the Resmed titration protocol. While you had a relatively high EPAP in your BiPAP titration, you need to start from scratch with ASV. I assume you are shooting for the Aircurve 10 ASV. The titration protocol recommended by Resmed simply puts the device on ASVauto mode and starts with Min EPAP at 4.0, Max EPAP at 15.0, PS min 3.0, PS max 15.0. I'm pretty sure you will require a higher EPAP min, but you can observe the results and make appropriate changes. These settings will get you there in just a few days of trial and error, and the data results will prove efficacy. Convincing your insurance that you have a prescription and will benefit from ASV and have a strategy for titration based on the manufacturer recommendation, may get the approval for the DME to dispense.

Page 41 https://www.resmed.com/us/dam/documents/...lo_eng.pdf

[xxyzx]

XXyzx, I share your sentiments on sleep labs and clinical titrations.  I think the only way you will convince your doctor and insurance to authorize the ASV is to start with with the Resmed titration protocol.  While you had a relatively high EPAP in your BiPAP titration, you need to start from scratch with ASV.  I assume you are shooting for the Aircurve 10 ASV.  The titration protocol recommended by Resmed simply puts the device on ASVauto mode and starts with Min EPAP at 4.0, Max EPAP at 15.0, PS min 3.0, PS max 15.0.  I'm pretty sure you will require a higher EPAP min, but you can observe the results and make appropriate changes.  These settings will get you there in just a few days of trial and error, and the data results will prove efficacy.  Convincing your insurance that you have a prescription and will benefit from ASV and have a strategy for titration based on the manufacturer recommendation, may get the approval for the DME to dispense.

Page 41 https://www.resmed.com/us/dam/documents/...lo_eng.pdf

my doctor prescribed the ASV
he wrote up a justification

the damn sleep lab talked my insurance rep into going back and redoing the test that was a virtual fail and a complete torture session

i need to get to the authorisers and possibly appeal but i will never ever go to a sleep lab for anything ever again no matter what 
i dont have the money
and i refuse to be tortured any more

[xxyzx]

Are you buying fully out of pocket, or insurance?

i am getting ready to ask insurance to pay for it
so far the lady i talked to did not want to see what the doctor wrote up
the DME fed her a line of crap that i think i got undone
then she called the sleep lab and got confused about what they had done
but sent me approval for a PSG for a CPAP

WTF!!

they gave me a bipap the first time
it failed
the doctor said so and justified it

There is no need to redo a useless test when i cant sleep at that place when they want you to.
and the environment is totally different so the results are more questionable.
Also one night is not as good as a month.

It would be cheaper to let me try the ASV at home and see how it works. 
It is possible that no machine can fix the CA and the OSA for me. 

I am getting all my ducks lined up information wise to be prepared to see their approval guy and bypass the so called service rep.

Hi xxyzx,

The PSG is usually the first overnight test, given to monitor your sleep without any CPAP machine.

You may be able to find a different sleep lab covered by your insurance which, after you show them the ASV prescription, will be able to help get an ASV titration preauthorized by your insurance.  Titrations are usually ridiculously expensive and I suggest not scheduling one unless it is preauthorized with insurance paying for it. 

You already have the prescription for an ASV machine, and if you want to pay for the machine out of pocket without help from insurance Supplier #2 on our supplier list presently has available relatively inexpensive gently used ResMed S9 Auto ASV machines for US$ 1,249 (REF# 36037).

But if you would want an insurance company to reimburse you, you would need to follow whatever rules they may have, which usually say an ASV titration is needed first to prove benefit, or else no reimbursement.

Your present bilevel settings are 11/14, which I suppose means 11 while exhaling and 14 while inhaling. This implies you need up to 11 while exhaling in order to prevent most obstructive events, and 3 higher when inhaling in order to avoid Flow Limitations.

The ResMed ASV machines have only a few settings and are largely self-titrating.  Settings of 9 for Min EPAP and 13 for Max EPAP would be two lower and two higher than your present EPAP setting of 11. A setting for Min Pressure Support of 2 or 3 would be around the same as your present PS of 3.  The Max PS setting must be at least 5 higher than the Min PS setting, and I would suggest using a Max PS setting of 10 or higher (but higher than 10 is usually not needed unless you have COPD or another unusual lung condition).

Take care,
--- Vaughn

i fought them for almost a month to get a copy of the rules
i had to write my congressman to pry them out of their hands

wtf
this is a contract 
everybody has a right to see all the rules

they dont have the right to hide them and keep making up crap to cause roadblocks when you satisfied the rules they first told you

now that i have the rules and get my technical info lined up i am sure they will see the light
and if not i will appeal it 

there is no point duplicating a test i had a few weeks ago for the same class E0471 device

auto titration has been in use for 20 years

i failed the bipap
my doctor said so and wrote up the justification for the ASV that the insurance rep didnt want to see 
he wrote the Rx

this is just bureaucratic delay hoping 'die gramma die' happens before they have to give me anything at all

[vsheline]

now that i have the rules and get my technical info lined up i am sure they will see the light
and if not i will appeal it 

With insurers I think it often takes two or more appeals.

The first appeal might only look whether their standard internal rules were applied.  If they were, the first appeal might be denied.

It might not be until the second or later appeal that they might consider whether their standard rules make sense in your case and whether an exception can be granted in your case. 

Best of luck to you in this.

[vsheline]

Hi Sleeprider,

Regarding:
"While you had a relatively high EPAP in your BiPAP titration, you need to start from scratch with ASV."

I think the ResMed and Philips Respironics titration guides for ASV are that if the previously titrated EPAP pressure (found needed to avoid obstructive events) was over 10, then the ASV titration can start with EPAP pressure between 6 and 8.

But I've read from other groups which recommend doctors to specify starting an ASV titration at the same EPAP or just a few cm lower EPAP than was previously determined to be needed.  (Personally,  this is would be my own recommendation, too, because I think many ASV titrations start and finish with EPAP too low.)

Always great to read your posts, my friend.

--- Vaughn

[Ockrocket]

And some people can't afford "real insurance"... 

You have all the options under the sun available to you, and yet you still feel hard done by because you are expected to comply to a tried and tested system of apnea trials. 

You continue to complain where others would be grateful to just have the opportunity to be tested in the first place.

[Sleeprider]

Hi Sleeprider,

Regarding:
"While you had a relatively high EPAP in your BiPAP titration, you need to start from scratch with ASV."

I think the ResMed and Philips Respironics titration guides for ASV are that if the previously titrated EPAP pressure (found needed to avoid obstructive events) was over 10, then the ASV titration can start with EPAP pressure between 6 and 8.

But I've read from other groups which recommend doctors to specify starting an ASV titration at the same EPAP or just a few cm lower EPAP than was previously determined to be needed.  (Personally,  this is would be my own recommendation, too, because I think many ASV titrations start and finish with EPAP too low.)

Always great to read your posts, my friend.

--- Vaughn

Vaughn, I am in agreement with you, and would normally acknowledge a need for higher EPAP in individuals with documented OA problems.  In this particular case, nothing has been presented other than a hearsay titration that didn't work.  Mainly the idea was to present a titration strategy consistent with the protocol, and I acknowledge higher EPAP is likely going to be needed in optimization.  I also think most people I have seen on ASV do better with 0-2 PSmin, rather than the 3.0 suggested in the protocol.  Again, the purpose here is simply to bypass a requirement for clinical titration.  I frankly don't see it as being much more challenging than an APAP self-titration, as long as the person doing it understands the data and likely responses to input changes. 

Always appreciate your insight Vaughn. You have always been someone worth listening to on the forum.

Tom