Sleep Apnea Claim

[EODCMC]

Hi, I am a 30 year retired vet. I retired 13 years ago. I as recently diagnosed with "very severe" obstructive sleep apnea. The machine they gave me is preset on the highest output flow. My episode exceed 35 times an hour with some lasting more than 30 seconds. 

I was diagnosed with sleep apnea a couple of years prior to retirement and the study and diagnosis is documented in my record. In fact, they wanted to operate on my uvula. There lies the rub. The operation could have ended my career so I didn't persue. Additionally, while on active duty I developed severe chronic sinusitis and allergic rhinitis and this also is documented in my service health record. I have been living with this and chalking it down to getting old.

Fast forward...I recently got a machine that they say I have to wear for the remainder of my life. I just learned that Tricare Prime does not pay for it all. So, I researched online and submitted a claim the E-benefits and it has been received and was under review until today when they changed this to "gathering of evidence" Development Letter Sent.

Does anyone know what this means? What do I have to look forward to concerning the process. I watch the news. It doesn't look good, right?

thanks in advance.

[Gastone]

Don't take the Claim Ltr to mean more than what it asks, you left info out that needs to be completed.

As to your Dr's SISOC, marginal at best. No indication that he actually reviewed your 2002 SMR DX of SA.

SC SA DX'd needing Cpap or Bipap is rated at 50%, even if you don't use the Machine, which would not be wise. If you also have a DX requiring supplemental 02 while sleeping due to P02's dropping below 90%, that does support a possible Chronic Resp Failure claim.

Check out the 38 CFR 4, SA Rating for 100%. You'll notice that there are 3 or 4 DX "OR'S" listed, any (1) of which could get you a bump to SA 100%.

That worked for me, this past 12/15. It took a VA Quality Review of a 07/15 increase Denial Decision, but the Sr Rater agreed with my position regarding my SA Request for an increase to 100%. Every thing regarding my 02 use and meeting another (2) of the 100% requirement was in my VMC records. The original Rater just didn't understand the significance of the "OR's" and the 02 Use. Got 100% Retro'd back to 01/14 with SMC S (1).

Semper Fi

 

[EODCMC]

14 minutes ago, Gastone said:

Don't take the Claim Ltr to mean more than what it asks, you left info out that needs to be completed.

As to your Dr's SISOC, marginal at best. No indication that he actually reviewed your 2002 SMR DX of SA.

SC SA DX'd needing Cpap or Bipap is rated at 50%, even if you don't use the Machine, which would not be wise. If you also have a DX requiring supplemental 02 while sleeping due to P02's dropping below 90%, that does support a possible Chronic Resp Failure claim.

Check out the 38 CFR 4, SA Rating for 100%. You'll notice that there are 3 or 4 DX "OR'S" listed, any (1) of which could get you a bump to SA 100%.

That worked for me, this past 12/15. It took a VA Quality Review of a 07/15 increase Denial Decision, but the Sr Rater agreed with my position regarding my SA Request for an increase to 100%. Every thing regarding my 02 use and meeting another (2) of the 100% requirement was in my VMC records. The original Rater just didn't understand the significance of the "OR's" and the 02 Use. Got 100% Retro'd back to 01/14 with SMC S (1).

Semper Fi

 

Gastone, thanks a lot for your comments and especially your recommendations. I'll check out 38 CFR 4, but I'm not O2, although I use the CPAP exclusively. It has really helped.

Yea, I'm only cautiously optimistic concerning the EFT stuff. There was one number off on my routing#.

I disagree with your assessment of my Dr.'s SISOC, however. The 1st para deals with my current sleep study. The entire 2nd para speaks to the sleep study in my SMR. Did I get that acronym right? I'm still scratching my head as to what SISOC means.

 

[EODCMC]

Ha...I got it! Statement In Support Of Claim (SISOC). Geez, I'm becoming a Hadit nerd.

[EODCMC]

Can I claim Hadit Nerd secondary to tinnitus? I wanted to ensure my 100th posting was worthwhile.

[Buck52]

The SISOC is usually meant as (Supplemental In Statement of Claim)

JMO

 

[EODCMC]

Thanks Buck, I thought I was getting it.