Adult CPAP Equipment Request Form This form should be used to request CPAP equipment for adults aged 18 years or over. Refer to Funding Criteria for information regarding clinical eligibility, eligible prescribers and equipment provided PERSON’S INFORMATION Last Name Title Ms First Name Mrs Mr Other Address Email Date of Birth Suburb Post Code Phone Mobile CLINICAL INFORMATION AND CRITERIA N.B. Full technical & physician reports of all relevant tests must be submitted with this request Please provide: Primary diagnosis: Any relevant secondary diagnosis/es or co-morbidities: BMI: 1. Diagnostic criteria Prescriber must tick and provide documentation for ONE of the following: AND 1. Oxygen desaturation index (ODI) ≥ 30/hr on overnight oximetry. Diagnostic ODI = OR 2. Apnoea Hypopnea Index (AHI) ≥ 30/hr on diagnostic polysomnogram (PSG) OR level 2 home sleep study. Diagnostic AHI = OR 3. Apnoea Hypopnea Index (AHI) ≥ 20/hr on diagnostic PSG OR level 2 home sleep study. Diagnostic AHI = PLUS clinical letter documenting one or more of the following comorbidities: Pulmonary hypertension, congestive heart failure, drug resistant hypertension, or stroke OR Central sleep apnoea (CSA)/ Cheyne Stokes Respiration (CSR) for the majority (≥ 50%) of respiratory events OR 4. Hypoventilation/ daytime hypercapnia: Awake PaCO2 ≥ 46 mmHg on arterial blood gas (ABG) taken during a period of clinical stability, awake / pm PaCO2 = OR A rise in PaCO2 of ≥ 8 mmHg from paired evening-morning ABG Awake / pm PaCO2 = ; If applicable: am PaCO2 = OR TcCO2 rising ≥ 8 mmHg from baseline on PSG 2. Screening for co-morbidities to determine CPAP application pathway Prescriber must assess the person for the presence of any of the following comorbidities: AND Does the person have any of the below comorbidities/ risk factors for hypoventilation: • COPD (with FEV1/FVC ≤ 70% and FEV1 ≤ 50% predicted) • Requires supplemental oxygen • Awake SpO2 ≤ 92% • Awake hypercapnia or hypoventilation syndrome • Morbid obesity (BMI ≥ 45kg/m2) • Heart failure • Chronic opioid use • Neuromuscular or chest wall deformity • Other significant sleep, respiratory or cardiac disorders (including CSA/CSR) No- Please provide treatment information as per 3a. Yes- Please provide treatment information as per 3b. If the person has been established on CPAP for > 5 years, please proceed to 3c. EnableNSW Adult CPAP Equipment Request Form – August 2021 1 Adult CPAP Equipment Request Form This form should be used to request CPAP equipment for adults aged 18 years or over. Refer to Funding Criteria for information regarding clinical eligibility, eligible prescribers and equipment provided 3. Treatment criteria 3a. Uncomplicated Pathway CPAP treatment requirements Prescriber must tick and provide documentation for ONE of the following: Auto-titrating CPAP treatment trial for ≥ 3 consecutive nights to determine the fixed pressure AND demonstrating a reduction in AHI to ≤10/hr. Treatment AHI = OR Recent (≤5 years) in-lab fixed CPAP pressure determination PSG (CPAP PD) demonstrating control of sleep-disordered breathing (SDB) 3b. Complicated/complex diagnosis pathway requirements Prescriber must tick and provide documentation for ONE of the following: In-lab CPAP titration PSG (preferred): Recent (≤5 years) in-lab fixed CPAP pressure determination PSG (CPAP PD) demonstrating control of sleep-disordered breathing (SDB) OR Only if in-lab CPAP titration study cannot be arranged, please provide: Auto-titrating CPAP treatment trial for ≥ 3 consecutive nights determining the fixed pressure AND demonstrating a reduction in AHI to ≤10/hr. Treatment AHI = PLUS Oximetry with detailed download from CPAP machine on prescribed fixed CPAP demonstrating stable gas exchange (including full technical and physician report) PLUS Letter outlining all of the following: (1) the person’s clinical history (2) that the prescriber has assessed the safety of CPAP for the person (3) reasons why a CPAP PD was not performed PLUS one of the following: Documentation of resting SpO2 >93% on room air OR Serum bicarbonate <27 mmol/L OR Arterial or capillary blood gas demonstrating PCO2 ≤45 mmHg 3c. Person has been established on CPAP for > 5 years Prescriber must tick and provide documentation for ONE of the following: The person was established on CPAP >5 years prior and is currently using CPAP. Please attach all relevant documentation including diagnostic and CPAP titration sleep study reports, other re

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