You have to have a physician's order (prescription) to get a BiPAP machine even if you do not plan to
seek insurance reimbursement so the first step is:
Finding a Doctor
Unfortunately, finding someone who is "cross trained" to understand both the effects of
neuromuscular disease on respirations and the respiratory assistance machines available can be
hard. The neurologist knows neuromuscular disease but diddly about the machines. The
pulmonologist (physician specializing in respiratory problems) knows the machines but not
In our screwed up health care delivery system someone might require that you see a sleep
specialist. The sleep guys are used to sleep apneaics who have good lung power and may be
unfamiliar with the problems of the neuromuscular patient.
Start with your neurologist. A neurologist who works with ALS patients should certainly be
familiar with BiPAP. He may handle your respiratory care himself, but may prefer to refer his
patients to a pulmonologist for respiratory care at that point. I would be reasonably
comfortable with either of them, but if I were sent to a sleep specialist I would most
definitely ask "How many ALS patients on BiPAP have you cared for?" and if he could not
demonstrate a very good understanding of ALS, I would be looking elsewhere.
The doctor who handles your respiratory care is going to be a very important person in your
care. Patients with ALS who do not want to go on a ventilator most often die of respiratory
failure so this doctor will be the one who sees you through to the end or sees you through many
years on a ventilator. You may still see other doctors, but odds are that this is the one who
will be there directing most of your care. You need someone who is comfortable not only in
deciding what pressure settings you need and dealing with any respiratory infection, but also
in listening, explaining and helping you make decisions about things like tube feedings, code
status, and whether or not to switch to full ventilation when BiPAP is no longer sufficient and
perhaps when to discontinue the ventilator. At some point he or she will likely be the
physician you depend on to make the end as easy and dignified as possible.
There are several tests doctors can do to monitor how much ALS is affecting breathing:
A respiratory function test involves huffing and puffing into a machine to see how much
lung capacity you have. The FVC (Forced Vital Capacity) which is basically how deep a breath
you can take is one of the most important findings of the test. At about 70% of normal you
begin to notice problems, less than 60% is considered moderate, less than 40% is severe. People
with neuromuscular diseases should have the test done while they are lying down as that is when
their breathing is the most impaired. A respiratory function test/FVC does not show whether you
have sleep apnea or if hypopnea is even worse when you fall asleep, however.
Another helpful test is a simple test of blood oxygen level. This is reported as Oxygen
Saturation (O2 Sat) percentage. An O2 Sat of 96% means that 96% of your red bloods cells are
carrying a full load of oxygen (are saturated) like they are supposed to be. Normal is 90% or
better (usually high 90's). O2 Sat monitoring can be done with a simple little device you clip
or tape on your finger tip. No needles! For us, the important thing is to wear the device while
lying down and sleeping. A spot check in the middle of the day will no doubt show excellent
levels when breathing problems first begin because our breathing is at its worst when lying
down and/or sleeping.
To accurately test you, your doctor can arrange for you to use an O2 Sat monitor at home
overnight. You just put the device on your finger at bedtime and wear it all night. It monitors
oxygen saturation and heart rate, and records it. The next day you return it, the results are
retrieved from its memory, and reported to your doctor. If you are breathing too shallowly
(hypopnea) your O2 Sat should drop. (CO2 levels would be more accurate in spotting hypopnea but
as discussed below, they are not as easily done accurately.) If you have apnea, your O2 Sat
will drop briefly but dramatically at repeated intervals.
These two tests along with a diagnosis of a neuromuscular disease such as ALS and a
description of the problems you are having should be sufficient to get a prescription for BiPAP
and insurance reimbursement for it. Unfortunately sometimes it gets more complicated.
Physicians and/or insurance companies may want more diagnostic evidence and want other tests
ABG's (Arterial Blood Gases)
Doctors tend to be irritatingly fond of these lab tests. ABG's require drawing blood
from an artery (usually in the wrist - an "uncomfortable" procedure). ABG's can tell a
doctor a lot more about your respiratory status than just oxygen levels. For example,
they tell the CO2 levels, can help determine if your breathing problems are due to lung
problems or other problems such as liver or kidney disease and even how well your body
is able to compensate for the problem. But ABG's are NOT always necessary.
Although ABG's are a perfect way of checking CO2 levels, they are a total waste of time
for the early stages of breathing problems in ALS if they are done when you are wide
awake and breathing normally! When breathing problems become severe CO2 levels will be
high even when you are awake, but not early on when you first could begin
benefiting from BiPAP.
DO NOT allow them to draw ABG's during a daytime appointment (unless you have some
other lung disease too) as a first step in determining if you need BiPAP. You have to
be in pretty bad shape to have a high CO2 while you are wide awake and being stuck in
an artery with a big needle! INSIST that the doctor explain what he needs to know from
the ABG's that he can't figure out simply by knowing that you have ALS and overnight O2
Sat monitoring. Your doctor may believe that the insurance company will reject a claim
for BiPAP without this bit of supportive evidence but I would ask him to file with all
the other info he has on you first and would not agree to the test unless the insurance
company rejected my claim.
Sleep Study Some physicians and/or insurance companies will want you
to have a sleep study done to verify the need for BiPAP. This expensive test involves
spending a night in a sleep lab trying to sleep while you are all wired up with
monitoring devices. The information will tell the doctor whether you have sleep apnea
and help determine what kind of pressure settings your machine will need. A sleep study
is necessary to get a diagnosis of Sleep Apnea, but for an ALS patient that should
not be necessary. The use of BiPAP for the breathing problems accompanying ALS
is well documented and standard care. Simply having a diagnosis of ALS and evidence of
the onset of breathing problems should be sufficient to justify ordering Bi-PAP. A
secondary diagnosis of sleep apnea or hypopnea by a sleep lab should not be needed.
But, depending on your insurer, you may have to jump through their hoops. Again, your
doctor may believe that the insurance company will reject a claim for BiPAP without
this bit of supportive evidence but I would ask him to file with all the other info he
has on you first and would not agree to the test unless the insurance company insisted
If you are required to have a sleep study, be aware that ABG's are commonly done with
them. Again it is important that the blood be drawn while you are asleep -- or as soon
after awakening as possible. (No one is going to sleep through an arterial blood draw!)
Ideally the blood should be drawn first thing upon awakening. I would refuse to have
the test done if it was not done at least before I was out of bed. I have heard of
instances where it was done after the patient was up to the bathroom, dressed, and
ready to go home! No wonder the ABG's did not support her need for BiPAP! You always
have a right to refuse a test or medication, and in this case not only is the test
useless but it will work against you in getting reimbursement for BiPAP!!!