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What is CPAP failure? Compliance, adherence & insurance

This term is used primarily by insurers, but it can be mistaken as judgment against sleep apnea patients who have given treatment a valiant effort but aren’t seeing a positive result.

What is CPAP failure, and why do they call it that?

The term CPAP failure makes it sound as if the user has failed to use the device properly, suggesting they are to blame for it not working. That’s actually not what CPAP failure alludes to.

From a user’s standpoint

CPAP intolerance may be a more useful term to explain why CPAP has not worked for them. When a patient cannot tolerate continuous positive airway pressure (CPAP), he is more inclined to avoid using it.

After all, if he’s given it a legitimate attempt to work and it’s not helping him to breathe better while asleep, and if he is sustaining unpleasant side effects that decrease his quality of life, he has good motivation to abandon therapy.

When CPAP fails in these situations, it’s usually because of things that are beyond the patient’s control:

  • Problems with nasal, sinus, or upper palate structures (in example, adeviated septum, swollen turbinates, high arching upper palates)

  • Problems with seasonal allergies or daily congestion

  • Problems related to coexisting conditions (unrelated sleep disorders, certain cardiovascular or pulmonary conditions)

These are generally “no fault” situations; the truth is, CPAP doesn’t or can’t work for everybody.

Meanwhile, there are patients for which the therapy is working and showing a benefit, and while they may not like using the therapy initially, they aren’t suffering from unpleasant side effects. They may be intolerant, but if they can use their therapy to a minimum standard over a long enough time frame, they would not be thought to have “failed” CPAP.

In these cases, patience, perseverance, and fortitude might be tools to employ until these patients have sufficiently adjusted to therapy to treat their sleep breathing disorders.

Usage is critical, however… Sleep apnea is a chronic sleep breathing disorder that does not go away on its own; people with sleep apnea must use some sort of therapy nightly in order to treat the problem.

Usage is also critical for a less dramatic, but no less important, reason: insurance companies will not reimburse for CPAP therapy (including all of the equipment) if it’s not being used.

From an insurance carrier’s standpoint

CPAP failure points to objective observation, supported by monitoring data, that shows the therapy is being used by the patient, but it’s not working for them. They are still having apneas, for instance, in spite of regular use and after troubleshooting for equipment problems.

Both insurance carriers and sleep specialists can review CPAP usage by way of built-in monitoring technology in order to confirm the patient is using therapy to a minimum. There is either a data card inside the machine that measures usage, which is then uploaded at the sleep clinic for review, or a wireless service that streams the same data live, directly to the clinic, through a modem.

The usage minimum is defined by the Centers of Medicare and Medicaid Services (CMS) as using CPAP at least 4 hours nightly for 70 percent of the time. Over a week’s time, minimum usage equals about 5nights out of 7, using it for at least 4 hours every night.

The terms used to demonstrate adequate usage are compliance or adherence . A patient is said to be compliant if their data proves measurable usage of 5 out of 7 nights for a minimum of 4 hours nightly. If they use their therapy less frequently, they will be deemed noncompliant by the insurance company.

While measures of compliance are based on Medicare definitions, most private insurance coverage for CPAP follows suit because the definition isn’t arbitrary; it also defines the minimum amount of therapy shown to be effective for staving off the dangerous cardiac problems that untreated sleep apnea can cause.

What happens if CPAP failure occurs?

When a patient first starts using CPAP, they will likely receive many phone calls and emails from their durable medical equipment (DME) providers or their physicians.

These sleep specialists want to ensure these patients have every opportunity to identify and correct problems with their therapies in order toachieve adherence. CPAP machine insurance coverage is based entirely on usage data, and their standards remain fairly rigid. But more important to sleep specialists is the desire for their patients’ success in finding long-term relief for their sleep apnea.

Sleep specialists understand that “one size does not fit all” when it comes to therapy and will do everything they can to prevent users from giving up. The first two weeks have been shown to be especially critical to the long-term success of compliant CPAP patients.

Interestingly, when it comes to insurance and CPAP, a patient’s outcome of CPAP failure may not necessarily be the worst outcome they could have.

Insurance companies follow protocols that are based on their need to control healthcare costs. They require that patients “fail” certain therapies (though, really, the therapies are “failing” them) in order to introduce newer options; more sophisticated PAP machines are, as one might expect, more costly.

This may lead to a patient’s sleep specialist introducing them to other kinds of noninvasive ventilation therapies, such as Bi-level PAP, auto-titrating PAP, or adaptive servo-ventilation (ASV).

Once these are attempted, if the patient still continues to be noncompliant, the insurer may then refuse to reimburse that patient for the machine or supplies and may even ask for the machine to be returned.

This is often referred to as a “use it or lose it” mentality among insurance payers.

However, in the event you simply cannot use CPAP, you do have options :

  • oral devices

  • outpatient procedures

  • weight loss

  • upper airway physical therapy exercises

  • neurostimulation implants

  • surgical removal of tissues causing obstructions

  • tracheotomy

Remember, you have sleep apnea, andCPAP therapy is generally considered the first-line treatment for this chronic health condition. If it doesn’t work for you, look on the bright side… it might actually lead to an opportunity to upgrade to a therapy you absolutely love! Sometimes CPAP failure can be a blessing in disguise.

Ultimately, the challenge may not even be about CPAP success, or avoiding CPAP failure, but about finding the best therapy to correct your specific sleep breathing challenges. For most, CPAP fits the bill. But for others, there’s no shame in “failing” CPAP if it means seeking one of the many alternatives and finding success.

If you are a first-time user and you have concerns about CPAP intolerance, consult your sleep specialist about your options and don’t give up!

The best sleep centers will be there, every step of the way, to help you find exactly what you need to most successfully treat your sleep apnea now and into the future.

Understanding how CPAP therapy works can empower you to stick with your treatment. Want to learn more about CPAP therapy? Check out our free e-book below for answers to common questions and advice for managing therapy challenges.


Sources:

American Thoracic Society
Centers of Medicare and Medicaid Services (CMS)
Cleveland Clinic
Sleep Dynamic Therapy
Sleep Review
Society of Behavioral Sleep Medicine

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