CDC Issues Warning About Nasal Washes

Nasal rinses can be very helpful for allergies, but can also be deadly:

http://denver.cbslocal.com/2012/02/28/cdc-issues-warning-about-nasal-washes/

" It’s because of a brain-eating amoeba called Naegleria fowleri" that can be present in tap water.

Many patients with sleep apnea use nasal rinses.... these are safe as long as boiled or distilled water are used. Similarly, tap water should not be used in CPAP humidifiers (distilled water is recommended).

Problems with the Respironics Compliance Download Report

Most sleep professionals are aware that Medicare now requires objective documentation of compliance with CPAP during the first 3 months of use for continued coverage of CPAP. During a consecutive one month period during the first 3 months, the patient needs to use CPAP at least 4 hours per night for 70% of the nights.

When looking at compliance reports from Respironics CPAP machines, I used to look at the % result of "Percent of Days with Usage greater than or equal to 4 hours". However, days in which CPAP is not used at all are not included in calculating this figure.

To get the correct "Medicare %", you need to multiply "Percent Days with Device Usage" by "Percent of Days with Usage greater than or equal to 4 hours."

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edit (4/9/09) When doing this calculation, make sure you are using a download report for a 30 day consecutive period (see comments)
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This problem was pointed out to a Respironics representative, and I think we will soon be seeing a more user-friendly compliance download report from Respironics.

Objective Compliance Documentation for CPAP use

A member of the AASM discussion boards provide a link to the following info regarding the new CMS requirements for the documentation of benefit of CPAP required for continued coverage of cpap beyond the initial 3 month period:

For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:
Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.

I am planning on asking the durable medical equipment companies I work with to provide me with a compliance download for my Medicare patients. The Medicare patients will bring this printout to their appointments with me.

This LCD applies to most of the southern states, I believe that most other regions have similar LCD's.

Obtaining Coverage for CPAP and CPAP titrations

Medicare and some insurance companies have strict criteria about covering the purchase of a CPAP machine for a patient. Here is my response to a question on the AASM discussion forums about getting CPAP and CPAP titrations covered for patients who have OSA/Upper airway resistance, but don't meet their insurance company's criteria for CPAP:

My understanding is that the MEdicare criteria (4% desat, etc), are for the coverage of the cpap machine. The actually cpap titration is covered if the attending feels it is medically necessary. So if the AHI (using 4% desat criteria for hypopneas) is less than 5, one approach would be to do a cpap titration-covered by Medicare- and then try to get a DME company to sell the pt a used, discounted cpap machine.

This approach also works with other insurance companies- usually diagnostic testing/titration is covered by a different department within the insurance company than DME. Though it may seem illogical, even insurance companies that have strict criteria for cpap machines will usually approve cpap titrations (at least in the state of Mississippi).

More on Portable Home Testing and Auto-CPAP

In response to a reader who emailed regarding my predictions of cpap vs. auto-cpap useage:

I don't think that APAP will entirely replace CPAP, but its marketshare will increase somewhat. This will be good for Respironics/RESmed, and bad for the durable medical equipment companies (DME's are reimbursed the same for cpap/auto-cpap machines and therefore there is a higher profit margin on the regular cpap machines for the DME companies). APAP will be prescribed in certain rural areas of the country by some primary care docs. After diagnosing a patient with portable home testing, they will tend to prescribe an auto-cpap machine rather than refer their patients to a sleep lab for a cpap titration. This will have little economic effect on the primary care doc, they will do this to maintain control of the process and maintain their independence from sleep labs. Some primary care docs, especially family practitioners in rural areas, take pride in being able to handle most problems themselves rather than referring to specialists.

More on Auto-CPAP

Currently there are a few major financial barriers to the use of Auto-CPAP:

Medicare and most insurance companies reimburse the DME companies for Auto-CPAP at the same rate as a regular CPAP machine. Auto-CPAP machines are more expensive (for the DME company) than regular CPAP machines. Unless a DME company is able to negiotiate a discount with the manufacturer, DME companies typically lose money on Auto-CPAP machines.

As far as using Auto-CPAP for an "at home titration study" (number 3 on my previous post)- that titration period (typically 3 nights) currently is unreimbursed and I am not aware of any plans for reimbursement for this.
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When portable testing is approved, I think that some primary care physicians will try to evaluate and treat osa without the involvement of sleep specialists by ordering portable testing and then treating the patient with an auto-CPAP machine (number 2 on my previous post). The auto-CPAP manufacturers have been known to negotiate discounts with large DME companies so this may be financially possible in certain areas. I think that we will see more auto-CPAP use by primary care doctors over the next several years, along with a temporary increase in profits by the Auto-CPAP manufacturers. However, results will be poorer than the current standard of having a patient undergo an in-lab titration before prescribing cpap. A lot of auto-cpap machines will end up sitting in closets and the auto-cpap trend will end by 2012.

I am not Responsible for your CPAP Machine

CPAP (Continuous Positive Airway Pressure) is the most common treatment for obstructive sleep apnea. Most sleep physicians do not directly provide their patients with CPAP machines, but instead give a prescription for each patient to take to a durable medical equipment (DME)company. I typically give patients a list of several companies to choose from, while telling them that they are legally free to pick any DME company they desire.
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Once a patient selects a DME company, he is essentially stuck with that company for 5 years. Due to reimbursement issues, it is difficult to switch companies (though there are a few exceptions- insurance reimbursement for CPAP is a complicated matter). Choosing the right DME company is critical- the DME company is responsible for adjusting the settings (as ordered by a physician prescription), supplying/fitting CPAP masks, periodically replacing filters and other supplies, and servicing the CPAP machines.
So pick a good DME company- go with your doctor's suggestion.
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Do not lose your CPAP machine. There is nothing I can do about it. Medicare and most other insurance companies won't cover a new CPAP machine for 5 years, unless your machine becomes unrepairable. If you lose your machine, you are out of luck.
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If you plan on moving soon, pick a national DME company, such as Lincare or Apria. If your DME company does not have an office in the state you are moving to, it may be difficult to get your CPAP machine serviced.
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I am not responsible for your CPAP machine. If it malfunctions, I will try to help out and will call your DME company, if necessary. However, I am often limited in what I can do. If you are one of my patients, please go to one of the companies that I recommend. I only recommend companies that provide good service.