Before I NOD, seeking input on SC sleep apnea

[Marine1342]

Hello HadIt Community,

TL:DR
Skip down to bold section “So that brings us to today….”

I've been a bit of lurker on the forums, searching and researching information already presented, hence the lack of postings.
I was not quite sure where to post this, in the “Appeals” section or the “Disability and Claims” section.”  I decided on the “Appeals” section due to the fact that the claim was already submitted and decided on, and so the next step logically would be an appeal.  Moderators, if it needs to be moved, please move it to the correct section.

I know that there is a lot of postings, questions, and information in regards to sleep apnea and trying to get it service connected, namely to PTSD and/or TBI.  I hope that by sharing my path/progress it will help others who are in a similar situation.

I am SC for TBI (70%), PTSD (50%), Mechanical neck pain syndrome (10%), tinnitus (10%).  Total combined rating with fuzzy math puts me at 90%.

This path of medical issues and nuances began in 2007 when I was in the Marine Corps, and it has taken my up until this year to really get most of my issues addressed and sorted.  What delayed the entire process would be attributed to not knowing the secondary effects to injuries.  Certain things were obvious (a head injury has secondary consequences like memory issues), but other things (namely the PTSD) were not.  The VA, for me, has done an excellent job in diagnosing things, as well as the therapy afterwards.  I know that this is not the case for everyone, but I was persistent and proactive towards trying to learn about myself and the changes I was going through and had been through.  Not having considered PTSD as a problem for me (denial maybe?), I had attributed everything (headaches, poor sleep, attention problems, behavioral changes) to the head injury.  Turns out that a lot of the symptoms of TBI are shared with PTSD, making treatment harder.  Is the poor sleep because of the head injury or the PTSD? If the memory and lack of focus because of the head injury or the PTSD, etc.

It took me a year and a half, after 6 months of initial therapy, to go through the medicine trial run.  Try different medications, see if I feel any different.  If I do, do I feel better?  Once the right medicine is found, then it’s about finding the best dosage for me.  Because everyone is different, and we are all wired differently, no 1 chemical will react the same way for everyone.  At times, it felt that nothing was really working, and it didn’t help that the trial period takes time for your body to adjust to the new drugs.  But with an open line of communication with my psychiatrist made it easier to track changes and make the changes so that I felt better.  For me, it’s been a night and day difference.  Looking back and remembering how I felt, it was almost as if my brain was in a constant fog.  I was awake and aware of things, but almost as if things were in a dream-like state.  I don’t know how else to describe it, but it felt like the drag I had on my mind and shoulders was eased.  There are still bad spells and moments, but that is where the discipline and focus really comes into play.  It hasn’t been easy, and I can’t even begin to imagine how it is for those who have a bigger challenge than I.  But what I do know, is that you need to be wanting to make things better for yourself.  It’s a bit of a process.  Therapy isn’t the easiest, as you need to revisit certain areas in your life that you don’t want to.  It takes time, and you feel quite low during certain times.  In some ways, it allowed me to learn more about myself, and what I needed to do and go through to make myself better (know yourself and seek self-improvement…).  But it gets better, I promise.

Biggest takeaway from disability claims with the VA, is to make sure you have your paperwork in order BEFORE you submit things.  At the beginning I did not know what I had, how the VA system worked, or anything at all.  So my first claim consisted of:  neck pain, lower back pain, headaches, memory problems.  Very broad and generic symptoms.  They were denied, but through the intake process, I did learn that I should talk to the VA clinic, namely the poly-trauma area to have my TBI assessed.  From there, it was evaluation after evaluation to try and get an answer as to why I was having problems.  TBI led to tinnitus and neck problems.  TBI therapy then lead to depression screening which led to PTSD screening.  PTSD screening then led to therapy.  Once those two main areas (TBI and PTSD) were stable enough for me, I started to address other issues, namely sleeping problems.  Headaches every day when I wake up, cold sweats every other night (changing sheets couple time a week….), nightmares.  I had attributed all those symptoms to the head injury, but that was when I had learned that it could be partially the head injury, and partially the PTSD.  More research lead to asking for a sleep study done.  I figured that if there is something going on while I sleep, maybe it’ll show up on the results and give me a better idea to what’s going on.  Having a better idea, it would allow me to attack the problem from a different angle.

I found that throughout the entire VA process (starting in 2007), the best way to tackle things is to focus on it like a puzzle.  Define the problem, get a better idea of what it is, and this then leads to knowing how you can attack it head on. 

I don’t know what exactly I was expecting out of the sleep study, but I certainly did not think that I would have an issue with breathing while I sleep.  I had assumed that my combination of injuries was manifesting itself while I was sleeping (my most relaxed state).  Long story short with my sleeping habits from the past, the sleep study showed that I had mild sleep apnea, namely obstructive sleep apnea.  CPAP machine was then issued.
Now to me, that didn’t make any sense at all.  I don’t fit the OSA poster-boy, at all.  Overweight?  Thick neck? Older? I’m 28, 6’, 165 lbs.  But I had some answers.  My shallow breathing would cause decreased oxygen intake which causes an increase in CO₂ in my blood.  Heart pumps faster, fight/flight response starts, body is working harder to supply blood to muscles, cold sweats start to try and dump CO₂.  Then I wake up and I have to go use the bathroom, 1-2 times per night.  I just figured I was well hydrated…haha…

With the answer of sleep apnea of the obstructive kind, I started to research causes for it, and correlations to different injuries.  One thing leads to another and there are correlations between head injuries and PTSD.  So at that point (more answers…yay), I go back to VA research and learn that there can be claims filed for OSA.  Since I was diagnosed with OSA outside of service, then I would need to either prove it happened while I was in (no evidence, so scratch that), or have a secondary connection to a service connected disability.
Seeing that I was SC for TBI and PTSD, that would be the route I would take.  What this meant was that I would need to present information to the VA showing a correlation between the injuries, and have the weight of a doctor behind it.
I made sure to file an Intent to File notice so that my date was locked in for retroactive pay.
With this date locked in, I needed to go about finding information on IMOs.  Researching and learning, I decided to go with Dr. Anaise and get an Independent Medical Expert Opinion.  $1500 later I had a nice sizeable book with him stating (and with evidence too) that he opined that it is more likely than not that my sleep apnea is secondary to my service-connected PTSD, TBI and tinnitus. 
With my new information and medical opinion in hand, I submitted a Fully Developed Claim, since I had no more information to submit (IMO from private doctor, and the VA had all my medical records including the sleep study).  6 months of waiting and checking eBennies (torture….) and it finally finished and showed that a decision had been made.  Paperwork comes in the mail and the claim is denied…

Frustrated? Not really, since I had expected that it would be denied.  Most claims, unfortunately seem to be denied the first time around.  Bit let down sure.  But it is what it is, I can’t change that, so now time to look at how to keep pushing forward.

 

 

So that brings us to today….
I do plan to submit a Notice of Disagreement to have it reviewed again.  I have been told that the reviewal process is in the time length of 2-5 years (frustrating but backpay will be nice…).
 

My posting on HadIt is based on wanting to get other people’s input and a fresh set of eyes on the information I have and what the next steps are, different viewpoints, and maybe anything I missed/am missing, as well as posting my information and path on here for others to read and learn from.

Medication:
Venlafaxine 300mg for PTSD
Zolpidem Tartrate 5mg for sleep (Ambien)

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VA Decision letter verbatim:

Issue/Contention

• sleep apnea

Explanation

• The evidence does not show that sleep apnea is related to the service-connected condition of traumatic brain injury, nor is there any evidence of this disability during military service.

• Service connection for sleep apnea is denied since this condition neither occurred in nor was caused by your service.

• Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.  The evidence does not show an event, disease or injury in service.  The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability.  The VA examiner stated that your current sleep apnea is due to the airways in your throat relaxing too much to allow normal breathing and closure of your muscles than your service connected TBI, tinnitus, and/or PTSD.

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VA Examination
I was not there for the exam because verbatim:
[X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

 

Verbatim:

MEDICAL OPINION SUMMARY

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opinion ---OSA 2/2 to PTSD

LESS LIKLEY THEN NOT THE OSA IS 2/2 TO PTSD --

RATIONALE --OSA IS A OBSTRUCTIVE DEFECT Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula ? a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood and cause a buildup of carbon dioxide. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it. You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long.

These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours. People with obstructive sleep apnea may not be aware that their sleep was interrupted.

In fact, many people with this type of sleep apnea think they slept well all night

 

/es/ *Name removed* FNPC

PRIMARY CARE PROVIDER

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IMO excerpts verbatim

“After reviewing the veteran’s c-file and the pertinent recent medical literature, I opine that is more likely than not that the veteran’s sleep apnea is secondary to his service connected PTSD, TBI and tinnitus”

“After reviewing all of the veteran’s medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is secondary to his service-connected PTSD and TBI.  The scientific observation that the derangement of REM sleep prominent in the PTSD patient is the cause for sleep apnea is of particular importance in this case.  It is more likely than not that the veteran’s sleep apnea is secondary to his service-connected tinnitus.”

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The report is 7 pages long with 5 5 exhibits of evidence (scientific journal reports).  If needed for better clarity, I can scan the 7 pages in (edited for privacy).
I can also post the findings from the sleep study if needed as well.

 

I don’t want to provide my thoughts and input on this just yet, as I would like to see what the community’s thoughts are on where things are so far, based on what there is.

What I ultimately am looking for, besides getting my claim granted, is to gain a better idea of what route I should take based on what I have.  The VSO who I was working with suggested a simple medical statement that says my medication for PTSD affects my OSA (throat muscles relaxing), was also recommended to have a DRO review the case (instead of a RO?) since it might speed up the process because it was more ‘in-house’. De Novo review? CUE?

Thank you in advance for your thoughts, view points, and suggestions

 

 

The CPAP machine, took a bit of time getting used to, but it is a night and day different (no pun intended ha).  The nightmares are less, the cold sweats are essentially gone, morning headaches aren’t there, and I feel rested now when I wake up and throughout the day.  Getting sleepy while driving isn’t there anymore.  I wanted to see its effectiveness, so I decided to try sleeping 2 nights without the mask, and the first night, instantly the prior symptoms came back.  Headaches, cold sweats, over tired all day.

 

My conclusion, from my personal experience, is that if you have PTSD, TBI or both, get a sleep study done.  There is strong enough correlation between the three to have symptoms overlap and exacerbate one another.  I may not know the exact scientific workings behind it, but logically it makes sense.  PTSD or TBI, get testing and therapy done to better understand the challenge that YOU have, and how to better work through/around/over it.  If they recommend medication, ask why.  Not to push back against it, but so that you understand what the purpose of it will be, how it will help you.  Self-knowledge and self-learning are very important in order to have a better grasp of things pertaining to you.
Be patient with medication, and be honest with your prescribing doc.  Everyone reacts differently to medication, and only YOU can determine how you feel.  I might even recommend keeping a small journal of how you FEEL throughout either therapy or medication trials.
Be patient with your meds.  Medicine doesn’t work overnight, especially finding the right one and dosage.
Be patient with therapy.  Not during therapy necessarily, but in the length of things.  It takes time depending on severity.  You will feel worse some days more than others.  Therapy, like medicine, is unique to YOU.  What worked for me, may not work exactly (or at all) for you.  But you need to be honest with yourself and with your guides (therapists and docs).

I had a small ‘good luck charm’, a grounding tool, that I would touch and hold when my mind would start to wander.  Helped to keep/bring me back to reality.  Grounding techniques worked wonders, but you need to be disciplined about it.  My good luck charm was a 550 cord bracelet I made when I was in.  Feeling the knots and mentally talking to myself kept me ‘here’.  Doesn’t have to be something big.  Just a small item that has meaning and significance to YOU.  You don’t even have to tell people what it is or does or anything.
But it gets better, I promise.

[Marine1342]

On ‎10‎/‎19‎/‎2016 at 5:38 PM, Marine1342 said:

So here is my view point/take on this situation.  Part of me wants to make sure I’m thinking clearly and correctly on this, and the other part of me is asking/wondering what the next step or proper steps are.

After taking a sleep study, I was diagnosed with OSA and issued a CPAP machine.  In order to get OSA with CPAP service connected either it was documented in service, or has to be shown to be a secondary to a SC disability.  In my case, I did not have it documented while in service.  So my other option is to show a connection to a SC disability.

I went and got an IMO that stated 50% or more that the sleep apnea is secondary to the SC PTSD, TBI, and tinnitus with documentation to support his statement.

C&P exam stated that OSA was not secondary to PTSD, and then proceeded to give me the definition of OSA.

The Notification Letter explanation is very short and states no evidence to support claim (uh..what about the 47 page IMO book?).

 

I feel as if the C&P statement was simply thrown together to process things quickly, and the letter explanation was also very short.  I have gotten letters before, all with a lot more detailed information.  Again, seems like it was just thrown together to move on to the next case.  It does list the evidence considered, so they did receive the documents from Dr. Anaise.

So what am I missing that would cause this to be denied? Or is this SOP, until a NOD is made and then reevaluated in more detail to then compare/pit VA information against Veteran information?

Maybe I don’t fully understand the ways of the VA process, and that is where my lack of knowledge has me stumped.  The way I see it, I have “all the checks in the boxes” and yet….

See quote above. Bumping this for hopeful input on others

[Gastone]

M1342, by now with your research on SA claims, your aware that a SA Secondary is not a Slam Dunk award.

A Solid Clinician's (Board Certified neurologist/Sleep specialist) Statement (IMO, clinician Treatment Notes) establishing an irrefutable linkage to your PTSD or SC Meds is necessary. Problem is, no Dr can opine with 100% certainty as to the actual causative factor, could be any number of the list of Usual Suspects (age, obesity, neck-tongue size etc) that could all be contributing to your SA.

The Secondary SA Award or reversal of  Denial will be determined by a Preponderance of Evidence in your favor or enough to get you to a "Jump Ball," "Benefit of Doubt" Award. If the "Evidence of Record" is equipoise, you get the Award, supposedly.

Semper Fi

[Berta]

GOOD point James.

Since this vet was working when he got the 90% the VA did not have to infer TDIU.

But they will have to consider TDIU now, if he files the formal 21-8940 claim for it and/or consider the 100%.

 

[Berta]

http://www.vba.va.gov/pubs/forms/VBA-21-8940-ARE.pdf

TDIU form.

And by all means apply for SSDI too.

if the SSDI does award, and you get notice of that prior to any TDIU award, and if the SSDI is solely for the SCs, this is great evidence to support the TDIU claim with so make sure the VA knows of the SSDI award..

[Gastone]

The Dr that wrote the IMO saying PTSD & TBI & Tinnitus are all 50% or greater as to causing your SA, what are his credentials?

Certainly would like to see the IMO he wrote as well as the Rater & DRO Denial Decisions.

Age isn't considered in IU Awards, I got mine at 67 06/14 and a good friend just got his DRO Decision IU Award 05/16 at 72.  It all comes down to your education, experience and recent Yrly Earned Income (last 12 Mos) being below the VA SGI Cutoff of $12,400 (under 65).

Just being out of work, unemployed or under-employed won't cut it. You have to prove that based solely on your SC's, you are unable to do any job, even Sedentary Work that could provide you with Earned Income in excess of the SGI.

Semper Fi

[Marine1342]

6 hours ago, Gastone said:

M1342, by now with your research on SA claims, your aware that a SA Secondary is not a Slam Dunk award.

A Solid Clinician's (Board Certified neurologist/Sleep specialist) Statement (IMO, clinician Treatment Notes) establishing an irrefutable linkage to your PTSD or SC Meds is necessary. Problem is, no Dr can opine with 100% certainty as to the actual causative factor, could be any number of the list of Usual Suspects (age, obesity, neck-tongue size etc) that could all be contributing to your SA.

The Secondary SA Award or reversal of  Denial will be determined by a Preponderance of Evidence in your favor or enough to get you to a "Jump Ball," "Benefit of Doubt" Award. If the "Evidence of Record" is equipoise, you get the Award, supposedly.

Semper Fi

Gastone:
I've learned and read that sleep apnea is not an easy path/route to go correct.  Some of the best pockets of information I have found have been where Vets had their documents/findings/IMO's etc, lined up to be submitted or ready to have an exam done in order to submit the information.  And I know that no Dr. can give a 100% certainty of a direct cause from one to the other.  But due to the "Benefit of Doubt" it makes it doable.  And really this "Benefit of Doubt" makes a lot of things doable, assuming information is presented to support two issues at a 50% or more, which is very appreciated.

And going into this, I knew that it was going to be a tough battle.  But I figured, with research and getting the information put together that supports my claim would help in the process.  Not a guarantee, but whatever I can do help out the process to benefit me, I'll push for.

47 minutes ago, Gastone said:

The Dr that wrote the IMO saying PTSD & TBI & Tinnitus are all 50% or greater as to causing your SA, what are his credentials?

Certainly would like to see the IMO he wrote as well as the Rater & DRO Denial Decisions.

The IMO was put together by Dr. David Anaise.  I think it was a pretty well put together document, granted I've never seen one or had one done, so skews my perception a bit.  Not sure what the privacy rules/requirements are, but I'm going to post the documents here (for reference only).  The documents would be the IMO, and then the letter of notification that the VA sent, as well as the Rater document (pulled from MyHealtheVet).

I think, that based on what I have, I'm not missing/lacking anything else, but wanted other people's eyes to double check.  My information vs. what the VA said/submitted, I think that its pretty solid, and it should be granted.  But there probably is a little bit of bias in that haha.
Looking at paperwork and documents and information over and over puts such a mental strain.  And it doesn't help that if feels like we only have 1 shot at claims with the VA.