The patient did not complete sleep diaries which confirmed the impressions above.

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1 History of the present illness: 70 year old patient went to the sleep lab at his wife s request in 2007 with the results shown below. He denied sleepiness at the time and denies that CPAP led him to feel better. States he ultimately got an Autopap (settings?) and has been using it regularly. However, in the last several months he has had increasing sleepiness and must take naps at home in the middle of the work week. Denies EDS while driving. Sometimes uses stimulants to stay awake. Wife says he is now snoring under his CPAP mask. The patient complains of: Excessive daytime sleepiness: Epworth Sleepiness Score is: 11. Insomnia Severity Index is: 10. The patient's usual bedtime during the week is 10:00 PM with 10 minutes required to fall asleep. The patient does complain of awakenings during the night. The number of awakenings is 4. The average duration of each awakening is 5 minutes. The final rising time is 8:00 AM. Patient or observer denies: breathing irregularity during sleep, dry mouth upon awakening, headache upon awakening, restless legs symptoms, sleep attacks, cataplexy symptoms, sleep paralysis, hypnogogic hallucinations Patient or observer complains of: snoring The patient did not complete sleep diaries which confirmed the impressions above. The patient presently uses 6 caffeinated beverages per day, use none alcoholic beverages per day, and 0 cigarettes per day. The patient has had prior sleep lab testing, revealing: IN 2007 showed AHI=57.2, with subsequent CPAP titration with resolution at CPAP=14 Sleep Intake Scores Beck Depression Inventory score: 6 Height: 200 Weight: 5'7" Sitting BP: 130/90 Sitting Pulse: 80 Neck Circumference: 18 (inches) Mandibular Overjet: 2 Condition of teeth: good Modified Mallampati: III Tongue size: normal Tonsil score: 0 Uvula: big Nasal Exam: clear and patent Chest: clear Cardiac: S1; S2; no murmur; no gallup Pedal Edema: none Assessment: Patient with OSA, using CPAP, with emergence of EDS Plan: 1. home Autopap download for adherence and AHI estimation 2. Home oximetry Time spent face to face: 45 minutes Time in Counseling: 30 minutes Return to office: 1 month(s)

2 Hypersomnia with Sleep Apnea (780.53) Periodic Limb Movement Disorder (327.51) History: 51 y/o male with here previously for OSA evaluation. Pt has an AHI of 87 with desats here today for a PAP titration study. Pt has diagnosis of hyperlipidemia and HTN Medications: Citalopram, Pravastatin, Androgel, Benicar, Amlodipine, Besylate, Nuvigil Epworth Scale: 11 Insomnia Severity Index: 8 Beck's Depression Scale: 16 Body Mass Index: 62.8 Mask Type: ResMed Mirage Quattro medium full face mask MONTAGE: This polysomnogram was performed with a sleep technologist in attendance. Six channels of EEG, ECG, EOG, Chin EMG, left and right anterior tibialis EMG, SpO2, nasal and oral thermistor, pressure transducer and Respiratory Inductance Plethysmography. All scoring was scored according to criteria set forth by the American Academy of Sleep Medicine, and hypopneas were defined as 50% reduction in airflow with either arousal or 4% O2 desaturation. Data acquisition, collation, and scoring have been validated and clinically correlated. SLEEP ARCHITECTURE: The patient was studied from 22:35 to 05:07 with a total time in bed of 393 minutes. Total sleep time was 256 minutes with a sleep latency of 10 minutes. Sleep maintenance efficiency was 65.1% with a total wake time after sleep onset of minutes. Sleep stage distribution, as a percent of total sleep time, was 3.7% Stage N1, 42.6% Stage N2, 32.2% Stage N3, and 21.5% Stage REM with a REM latency of 83.5 minutes. There were 65 arousals associated with respiratory events, 57 arousals associated with leg movements, as well as 25 spontaneous arousals, for a total arousal index of 34.5 per hour. RESPIRATORY INFORMATION: Respiratory event distribution revealed a total of 10 obstructive apneas, 11 central apneas, 0 mixed apneas, and 53 obstructive hypopneas. The total apnea index was 4.9. The total hypopnea index was The total Apnea Hypopnea Index was REM sleep accounted for 55 minutes with a REM related AHI of 2.2 events per hour. The patient slept in the supine position for a total of 209 minutes with a supine AHI of 15.5 events per hour. The patient slept in the side position for a total of 47 minutes and a side AHI of Absence of Cheyne Stokes breathing. OXIMETRY DATA: During the sleep study, the maximum O2 saturation was 95% with a minimum O2 saturation level of 78% and a mean O2 saturation level of 89%. Total desats were 39. CARDIAC PROFILE: Baseline wake heart rate was 79.5 with an average heart rate of 73 during sleep. Absence of bradycardia, Absence of tachycardia, Absence of asystole, Absence of atrial fibrillation.

3 LIMB MOVEMENT INFORMATION: The total number of PLM was 121. The number of plm with arousals was 57. The PLM index was 28.4 with a PLM arousal index of CPAP DATA: CPAP / BIPAP / Supplemental O2 Data PAP(cmH2O) O2(l/min) TST (min) RDI (#/hr) Mean SaO2 (%) INTERPRETATION: CPAP explored Pressures of 10 or greater were associated with improvement compared to baseline, but the best pressures were 14 and 16, with nearnormalization of sats and 0' for AHI. REM on back seen at CPAP=16, so 16 is recommended. He also had mild PLM, but treatment of PLM can be deferred until OSA is treated CLINICAL CORRELATE: CPAP treatment of 16 cm H2O

4 Hypersomnia with Sleep Apnea (780.53) History: 36 yr old wf with complaints of loud snoring by family, eds, and breathing irregularity in sleep. Pt here to r/o osa Epworth Scale: 17 Insomnia Severity Index: 11 Beck's Depression Scale: 8 Body Mass Index: 38.8 Neck Size: 17 in. MONTAGE: This polysomnogram was performed with a sleep technologist in attendance. Six Channels of EEG, ECG, EOG, Chin EMG, left and right anterior tibialis EMG, SpO2, nasal and oral thermistor, pressure transducer and Respiratory Inductance Plethysmography. All scoring was scored according to criteria set forth by the American Academy of Sleep Medicine, and hypopneas were defined as 50% reduction in airflow with either arousal or 4% O2 desaturation. Data acquisition, collation, and scoring have been validated and clinically correlated. SLEEP ARCHITECTURE: The patient was studied from 21:35 to 04:28 with a total time in bed of minutes. Total sleep time was 381 minutes with a sleep latency of 13 minutes. Sleep maintenance efficiency was 92.1% with a total wake time after sleep onset of 19 minutes. Sleep stage distribution, as a percent of total sleep time, was 13.8% Stage N1, 56.4% Stage N2, 16.5% Stage N3, and 13.3% Stage REM with a REM latency of minutes. There were 131 arousals associated with respiratory events, 35 arousals associated with leg movements, as well as 53 spontaneous arousals, for a total arousal index of 41.3 per hour. RESPIRATORY INFORMATION: Respiratory event distribution revealed a total of 9 obstructive apneas, 2 central apneas, 0 mixed apneas, and 123 obstructive hypopneas. The total apnea index was 1.7. The total hypopnea index was The total Apnea Hypopnea Index was REM sleep accounted for 50.5 minutes with a REM related AHI of 7.1 events per hour. The patient slept in the supine position for a total of 77 minutes with a supine AHI of 28.1 events per hour. The patient slept in the side position for a total of 304 minutes and a side AHI of Absence of Cheyne Stokes Breathing

5 OXIMETRY DATA: During the sleep study, the maximum O2 saturation was 99% with a minimum O2 saturation level of 90% and a mean O2 saturation level of 96% total desats were 31. CARDIAC PROFILE: Baseline wake heart rate was 75.5 with an average heart rate of 78 during sleep. No bradycardia, No tachycardia, No asystole, No atrial fibrillation. LIMB MOVEMENT INFORMATION: The total number of PLMs was 38. The total number of PLMs with arousals was 35. The PLM index was 6. with a PLM arousal index of 5.5. INTERPRETATION: This patient has a moderate degree of sleep disordered breathing CLINICAL CORRELATE: Sleep study with CPAP

6 CPAP DOWNLOAD EXAMPLE Summary of Compliance - All Data Compliance Statistics Date Range 04/03/ /26/2010 (115 days) Days with Device Usage 115 days Days without Device Usage 0 days Percent Days with Device Usage 100% Cumulative Usage 1029 hrs. 57 mins. Maximum Usage (1 Day) 15 hrs. 57 mins Average Usage (All Days) 8 hrs. 57 mins. Average Usage (Days Used) 8 hrs. 57 mins. Minimum Usage (1 Day) 39 mins. Percent of Days with Usage 4 hours 78.3% Percent of Days with Usage < 4 hours 21.7% Total Blower Hours (During Reported Period): 1029 hrs. 58 mins. REMstar Auto Statistics Auto-CPAP Mean Pressure 4.8 cm H2O Auto-CPAP Peak Average Pressure 8.0 cm H2O Average Device Pressure 90% of Time 6.3 cm H2O Average Time in Apnea Per Day 1.9 mins. Average Time in Large Leak Per Day 13.2 mins Average AHI 3.3 Adapted from: Apria Healthcare Winston S

7 CPAP DOWNLOAD EXAMPLE Patterns of use April, 2010 May, 2010 Adapted from: Apria Healthcare Winston S

8 CPAP DOWNLOAD EXAMPLE Patterns of use June, 2010 July, 2010 Adapted from: Apria Healthcare Winston S

9 GENERIC - CONFIRMATION OF ORDER Dear Physician, The following information was provided to our office as part of the order intake process. Please confirm that the information is correct. If the information is correct it needs to be inserted into the attached Written Order Form. Any changes or correction should also be inserted into the attache dform. Once all sections of the Written Order are completed, please sign and date the order. Thank You. Questions Reviewed: Answers: Diagnosis of patient? Obstructive Sleep Ap Hypersomnia w/ Sleep Estimated length of need? 1-99 (99 = Lifetime) 99 Prognosis of patient? (1 = good, 2 = fair, 3 = poor) 2 DIAGNOSIS ICD-9 Code / Description Obstructive Sleep Apnea (adult) (pediatric) Hypersomnia w/ Sleep Apnea EQUIPMENT / SERVICES Qty Proc. Code Item Name / Narrative 6 A7038 Pos airway pressure filter Signature: Date: 8/16/10

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