BiPap vs Auto Cpap

[mjsbouchard]

I have used a bipap for 12 years set at 6/3 after my sleep study back then. I have polio so I was told it works like a respirator for me at night and sometimes during the day.
Got a new home sleep study done in Jan 2019 and my insurance approved me to have a new machine, mine is 12 years old.  The study said I needed adjustments from 5 to 15.
The insurance approved a Dreamstation  DSX 500 H11C which the company says is an auto cpap, but I have tried it for a week and wake up more tired than when I went to bed. I am also bloated and have pains in my ribs.  My doctor sent a report to say I needed a bipap but he is a gp, not a sleep specialist and I got told I had to use the one the insurance approved.  I gave up on the new one after a week and went back to my old machine because I was waking up with 88, 89 PO on my pulse ox.
Is there a way for me to prove to the insurance company what I need, I was told if I don't use it for 3 months I have to pay the full amount for the machine.
Sorry for such a long first post.
Megan

[Sleeprider]

Megan, welcome to Apnea Board. Your long post will be shorter than my response. As a user of bilevel therapy, with the comorbidity of childhood polio, it should be very easy to be approved for bilevel. Insurance usually follows Medicare guidelines for approval of a bilevel machine.  Section 60-9 of the Medicare Coverage Issues Manual provides that ventilators are "covered for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. This includes both positive and negative pressure types." There are no national coverage guidelines on RADs specifying criteria for meeting the conditions for its intended use.

The criteria for upgrading from CPAP to bilevel is simply the doctor's statement of medical necessity, which in your case is very easy. Your intolerance of CPAP vs BiPAP, as demonstrated by your results and need to return to your old machine, is further evidence of medical necessity.  The simple explanation is that bilevel positive air pressure unloads some of the respiratory effort from you to the machine. Your inability to sustain a good minute vent and tidal volume is sleep is directly related to your medical history, and this history qualifies you for coverage of bilevel therapy, absolutely no question about it. Your doctor merely needs to form an opinion of medical necessity based on what he knows about your and your medical history. This is supplemented by your poor response to CPAP, and the known efficacy of your previous bilevel therapy.

The CPAP machine you were prescribed is the worst choice. Had you been provided a Resmed Airsense 10 Autoset, you could have had at least 3-cm of pressure support. The Resmed machines provide exhale pressure relief that works like bilevel with up to 3-cm pressure difference between IPAP and EPAP.  You could have had the Airsense 10 Autoset provided with a minimum pressure of 7.0, maximum pressure of 15.0, and EPR at a setting of 3.  This would have offered a range of 7.0/4.0 to 15.0/12.0 in true bilevel delivery.  Of course the Aircurve 10 Vauto offers even more pressure support to treat your neuomuscular respiratory deficiency.  I think you will need to be persistent and try to get the Resmed Aircurve 10 Vauto bilevel machine.  If you have relatively high deductibles or things get ridiculous, just have your doctor prescribe it, and you can get one relatively inexpensively (about $750) from Supplier #2.

You can discuss this with your GP and use these linked resources to understand how insurance approves these devices (Respiratory Assist Device (RAD) with or without a backup rate).
https://www.resmed.com/us/dam/documents/...elines.pdf
https://www.cms.gov/medicare-coverage-da...AAEAAA&
https://www.cgsmedicare.com/jc/mr/pdf/mr..._e0471.pdf

[mjsbouchard]

Thank you so much for your help, I will be contacting the insurance again today.

[Sleeprider]

It is important to emphasize you don't have conventional obstructive sleep apnea, but neuromuscular hypoventilation. You may have some obstruction as well but you seem to have been successful at low pressures. Again, it is the pressure support (difference between inhale and exhale pressure) that makes it easier for you to breathe and remain oxygenated. The alternative might be supplemental oxygen delivered from an oxygen generator. It's not a bargain for your insurance company to deny bilevel.