DME

Patient with suspected sleep apnea:

Complete Epworth and Stop Bang Scores in EPIC flowsheets (this is necessary for insurance coverage).

normal scores do not rule out sleep apnea, rather have a high + predictive value and justify the procedure.   If you still strongly suspect sleep apnea you can still order but will have to make sure documentation clear.    

ALL Patients MUST HAVE A FACE-FACE visit that includes OSA/medical risk factors, signs and symptoms why you think they have sleep apnea and includes objectives scores.  Virtual video visits count, but not phone or MHC messaging.  diagnoses such as obesity or a fib do not qualify on their own without other symptoms.   

You can choose to manage sleep apnea OR you can refer to sleep medicine to review the results.  

Refer to Sleep Medicine for severe nocturnal hypoxemia (mean nocturanal sat < 85%, not just intermittent mild desats), complex pre-existing cardiac/pulmonary/neurological disease, suspected or known central sleep apnea, need for BiPAP or more sophisticated modes of ventilation.  If you suspect more complex sleep apnea you can order the in-lab sleep titration study and refer to sleep medicine at the same time.

Order appropriate sleep study:

• Home studies are appropriate for those who have a moderate to high pre-test likelihood of having OSA (obvious symptoms, positive Epworth/STOP BANG scores) and do not have major comorbidities.

• Use the sleep study panel (in fmc favorites) to order study and decide if you want an automatic referral to sleep medicine. 

• If suspected central sleep apnea or questionable dx should have in-lab split-night sleep study and sleep medicine follow-up. In lab studies preferred for patients with O2 dependent lung disease (severe copd/etc), CHF (high risk of central apnea), recent CVA, high dose narcotics, suspected sleep problems that are not clearly OSA.

Order CPAP/supplies with clear OSA w/o severe nocturnal hypoxemia (> 85% mean sat):

Order auto-titrating machine as per recs from home sleep study read with mask of choice, heated and humidified.  If the patient had an in lab study order as per those recommendations.

Michael Jacobson’s standard order is:

Resmed machine, Airsense 11 auto CPAP@ 5-14 cmH2O, EPR 2, auto ramp from 5, heated hose, mask of choice, NO BRAND SUBSTITUTIONS (there are other knock off brands that are less good)

Follow-up Recommendations/requirements:

• Must document review of a compliance report within 31-90 days of initiation of CPAP and a face-face visit.   You need a copy of the downloaded report for the chart. Your face-face compliance visit must include in writing that the patient “is using and benefiting from their cpap” - video/in-person ok, phone/mhc not ok

• Compliance report must document at least 1 month of CPAP use of at least 4h/night on 21/30 days (70%) in order for them to keep their machine.

• Make sure AHI is < 10/h. If patient is struggling with compliance or has ongoing apnea, refer to Sleep Med.

• If patient has significant nocturnal hypoxemia on their initial home sleep study they will need a nocturnal pulse ox after demonstrating regular use of their cpap and may need O2 bled into their CPAP. This should be done if O2 sat < 87% on initial sleep study.  If still low medicare and medicaid require an in-lab titration to confirm low sats AND a secondary diagnosis such as chf, copd, pulm htn to qualify for home O2

• Ongoing must have a yearly visit to discuss CPAP use and review compliance report. The patient can have the O2 company download a compliance report (**or we can request access from device reps to their online data based to download compliance reports on our patients)

Testing/Injection Supplies

CGM

Shoes

Walkers

Canes

Wheelchairs (manual/power)

Hospital Beds

Blood pressure monitors

Wound care

Ostomies

Nutrition/Entereral

Uroogy/catheter

Nebulizers