syne7

I personally think this is good advice. In my experience VSOs are loose cannons and don't have the time to coordinate with you. They are possibly "good meaning" individual. However, if you have the time to follow and care about your claim, no one is going to be as good an advocate for you than yourself. Once you get to appeal you could consider a lawyer.... Thought my impression is the first appeal (BVA) you can handle yourself. Just my thoughts and there are many others who are more experienced here. I am batting 100% on my own been working on this since 10/2015. Just one a CUE moving EED to 1997 and unadjudicated claim back to 2001. Won both on first submission with no appeal. The info here was a big help. I have a new claim in (2 increases and 2 previously unclaimed conditions) starting now. We'll see how it pans out. So my perspective is "fresh" and untested.

Here is the statement I put in my tinnitus claim. I will let you know how it turns it. It appears they are sending me to an hearing exam: I understand that according to VA Training Letter 10-02 and 38 CFR 3.385, if service treatment records mention a complaint of tinnitus, the veteran claims tinnitus, and has current complaints of tinnitus, a medical opinion regarding possible causation is not required. Service connection can be established without an opinion about the specific cause of the tinnitus because it began in service.

What is NMO?

Thanks for the clarification. So the issue is: 1. You have been diagnosed with Sleep Apnea. 2. You would like to service connect your Sleep Apnea and make a claim for disability. Is that correct? Next questions are: 3. Have you made a claim? If so, have you had a C&P Exam? Thanks...

Immediately reply with disagreement. I think you have 30 days to respond. Couple of things to explore. Have you been rated for more than 5 years? if so, I don't believe they can reduce you based on one exam or because the condition is "episodic". So first question. Have you had the rating for more than 5 years? Second question. Have you had a C&P exam? If not you should consider requesting one (if they not scheduling). Third. If you do go to an exam. Familiarize yourself with the criteria for 0%, 50%, 70% etc... Make sure you properly express your symptoms and consider doing so in writing to be officially submitted. Fourth. Once you have that consider a DBQ of letter from your doctor or new doctor if necessary to document your current state. Fifth. Be careful, but don't panic. A new exam could yield same rating, or higher rating as well as a lower rating. If you are over 5 years... and have a bad exam, here is a sample response of why they can't lower you immediately. if the rating is a "stabilized rating",in place for more than 5 years, the rating may not be reduced unless all of the evidence in VA records shows that there is "sustained improvement." The nature of conditions such as mental wellness are variable and subject to episodic improvement. One exam does not show 'sustained' improvement. Given the medication nature of the issue, it's easy for a given day to be a "good day." and another day to be a "bad day." The protocol for sustained improvement requires at least two exams in a 5 year period. Accordingly, the requirements under 38 C.F.R. § 3.344(a) and (b) (2014) should apply in this case and would merit multiple exams - per 38 C.F.R. § 3.344(b) (2014).

Have you done a sleep study? Have you been diagnosed with Sleep Apnea in the past? Is the sleep lab order a new evaluation or a re-evaluation of an existing SA condition?

Depends on what the neuro exam says etc... But really, you just need other Dr's opinion's that support your position. I am finding the real trick is IMO's/IME's/Nexus. Do you have access to private physicians?

While studies are useful. Unless its specific to you or Veterans. It really takes a Dr's opinion. I know that getting Nexus letters is a challenge. However, it's work seeking out Dr's you deal with to write them or finding a professional IME/IMO Dr. who does that for a living. In the end it's mostly the Dr's opinion (C&P Examiner or IMO/IME/treating physician) that counts. The nice thing is that opinions can differ. Go find a Doctor that understands your position and can support it (if possible). I think it worth putting the effort into getting the paperwork (official Dr stuff) to support you claim rather than statements and arguements on your own. These can help but the impact of dr's statements are so much more impactful in my opinion. Of course one should do everything one can.

It's worth applying for the claim and getting a 0% rate in case later it gets worse. Since you are filling a claim, you could consider pursing PF.

Here is another http://www.va.gov/vetapp14/Files4/1427494.txt

Apparently sleep apnea can be secondary to MDD. http://www.va.gov/vetapp09/files2/0911508.txt You need to consider getting opinions, nexuses, and IMO's/IMEs

I believe you can request a doctor change with a form.

Go see another Doctor.

It sounds like you have the two items: in service issue and current issue well documented. What you need now is Nexus connecting the two. This can be done with a letter from your doctor. The veteran is also competent of reporting his symptoms over the years. So you can write your own statement of condition and symptoms documenting that you had the problem since service and what you experienced up until now. From my memory, I believe a rating of 10% for plantar fasciitis, your symptoms have to not be relieved by inserts. You might want to look it up. So I think the next thing you can add to document your claim is a statement that describes your ongoing treatments (inserts) and pains etc... since you got out. Buddy statements from family or veterans would not hurt either.

I think it depends on the amount and the likeliness of primary/secondary. I am taking this from a gut point of view. I exited the Army in '97 and was medically discharged for asthma and left ankle. I was given 10% for asthma and 0% for ankle. They also looked at both feet and did not SC for fractures. Fast forward to 2015 and I learned more about what the VA was and how it worked. I obtained a copy of my c-file and SMR. I have identified about 15 claims based on in service issues and my current conditions for the following areas: Diabetes, left foot, right foot, left ankle, right ankle, left knee, right knee, back, right wrist, right thumb, asthma, sleep apnea, hearing loss, tinnitus, sinusitis/rhinitis. To make my claims harder. I have lived in several places and often just used urgent care for the past 20 years. Most doctors don't keep your records after 5-7 years depending on state regulations. Accordingly, I am putting my claims in a few batches. I feel this that 18 or so would be over whelming and also there is some synergy for raising my left ankle to use as to claim other as secondary. So I am claiming the foundational/easier claims first and working to other groups. Here is the strategy I worked for myself: 1. Pending claim for diabetes from 2001 (Just won) 2. Increase: asthma & left ankle. New claim: Sleep Apnea (primary & secondary asthma, diabetes, left ankle), & Tinnitus (Just started two weeks ago). 3. New claim (re-open): left foot, right foot, right ankle, left knee (to be put in after decision on 2). 4. New claims: right knee, right wrist, right thumb, sinusitis (to be put in after 3). Many have counseled me to put them all in at once. However, I feel like I will be on stronger ground if my ankle is rated 30% or 20%. In the meantime I am learning about the process as I go and collecting nexus's and IMEs and building history. I also feel like the humans in the process will be negative if they see 15 claims after 20 years. This effect may not be true as it's purely my opinion and may not apply to you since you only have three things. If I had 4 or less I would submit them all at once. I welcome any comments on the subject or my personal choice and situation.

I put in a FDC two weeks ago for increase asthma increase left ankle tinnitus sleep apnea I am now waiting for C&P exams. I haven't been contacted yet, bit I called Peggy and they said they were contracted out to QTC. hope to have them done this month. I submitted the IMO with the claim and an appointment for an IME on 6/1 a backup. i also submitted a weak nexus letter from my sleep neurologist which states, " after reviewing the veteran's medical records, I have come to learn he has asthma. His obstructive sleep apnea is exacerbated when having an asthma attack." if they deny, which I expect, I will then have the IME in June ready to follow-up for DRO review or appeal.

We'll know shortly... LOL... Though I think the Sleep Apnea is redundant with my asthma. I think you get a combined rating for the two. If the asthma upgrades to 60%... the Sleep Apnea will be extra.

He did, 3 board certifications, 5 medical patents. Authored over 100 papers He is a doctor and an attorney.

I have. I am awaiting C&P Exam. I will keep everyone posted as to how it goes.

Here are some snippets from my SA IMO, in case anyone wants to a see sample of what's out there. I'd appreciate any thoughts or opinions on the content as well: Sleep apnea secondary to service-connected asthma I opine that the veteran's sleep apnea is more likely than not secondary to his service ­connected asthma. Several studies have confirmed that asthmatic patients are more prone to develop OSAS symptoms than are members of the general population. The common asthmatic features that promote OSAS symptoms are nasal obstruction, a decrease in pharyngeal cross sectional area, and an increase in upper airway collapsibility.i The August 2007 National Asthma Education and Prevention Program Expe1i Panel Report 3 (EPR3) recommends that clinicians evaluate symptoms that suggest OSAS in unstable, poorly controlled asthmatic patients. Patients with OSAS have an increased vagal tone during sleep as a consequence of paiiial or complete airway obstruction occurring during apneas. The mechanics of this potent vagal stimulation are similar to those of the Muller maneuver, which consists of an inspiratory effo1i against a closed glottis. Increased vagal tone occurring during apnea episodes could be a trigger for nocturnal asthma attacks in sleep apnea patients. ii In fact, several studies have shown that increased vagal tone stimulates the muscarinic receptors located in the central airways leading to bronchoconstriction and causing nocturnal asthma. Furthermore, suppression of the increased vagal tone by inhaled anticholinergic drugs leads to improvement in forced expiratory flow, reduction in early morning falls in peak expiratory flow, and protection against nocturnal astluna symptoms. iii Another factor in the neural reflex mechanism involves the neural receptors at the glottic inlets and in the laryngeal region; these receptors have powerful reflex bronchoconstrictive activity. Nadal et al showed that mechanical irritation of the laryngeal mucosa increased total lung resistance distal to the larynx. Sleep apnea secondary to chronic pain from service-connected ankle ankyloses I opine that it is more likely than not that the veteran's sleep apnea is secondary to his chronic pain syndrome due to his left ankle injury. Clu·onic pain and disrupted sleep are commonly associated, and they share a clear cause-and-effect relationship. A bidirectional relationship exists between pain and sleep disturba11ces. Pain fragments sleep continuity, impairs sleep quality, and disrupts normal sleep architecture. Reciprocally, poor quality or insufficient quality of sleep may decrease the pain tlu·eshold, impair recovery from injuries, or further exacerbate the pain response. Painful stimuli produce micro-arousals which disrupt sleep continuity and alter normal sleep. Chronic pain is associated with increased high frequency EEG activity and a decrease in slow frequency EEG activity. Furthermore, chronic pain is associated with the appearance of alpha waves superimposed on slower EEG frequencies, or "alpha-delta" sleep. In short, pain produces a state of shallow sleep while disrupting restorative slow-wave sleep. An estimated 28 million Americans have sleep complaints due to chronic pain syndromes. Among patients with chronic pain, more than 50% experience sleep disturbances. Some repotis show that as many as 70% - 88% of patients with chronic pain repoti sleep trouble. Sleep disturbance shows an independent and linear correlation with pain severity, even after controlling for health measures and sleep habits. Sleep complaints portend worse outcomes among those with chronic pain. Dr. Vincent Mysliwiec, et al, reported in Sleep Disorders and Assodated Medical Comorbidities in Active Duty Military Personnel [Exhibit 4]: "Military personnel with the diagnosis of pain syndromes were more likely to have insomnia. Poor sleep is a recognized symptom in individuals who have medical disorders associated with pain. Previous studies using both questionnaires and PS Gs have reported patients with pain have difficulties initiating and maintaining sleep, supporting the association of pain syndromes with insomnia.v In the study's cohoti, 24.7% were identified as taking medications for pain." Sleep apnea secondary to service-connected diabetes mellitus type 2 I opine that the veteran's sleep apnea is more likely than not secondary to the veteran's service-connected diabetes mellitus type 2. There is a high prevalence of OSA in people with Type 2 Diabetes and abnormal glucose metabolism, which may in part be explained by obesity. Conversely, people with OSA have a high prevalence of Type 2 Diabetes and related metabolic disorders. There is a link between OSA and daytime somnolence. Sleep-disordered breathing (SDB) has been associated with insulin resistance and glucose intolerance, and is frequently found in people with Type 2 Diabetes. SDB not only causes poor sleep quality and daytime sleepiness, but has clinical consequences, including hypertension and increased risk of cardiovascular disease. The International Diabetes Federation (IDF) Taskforce on Epidemiology and Prevention convened a Working Group in February 2007 to review the subject_Yi OSA based on overnightpolysomnography has been noted in up to 9% of women and 24% of men. Cross-sectional surveys show that obesity (particularly central obesity) is the strongest risk factor for OSA; male gender, age and ethnicity also contribute. Some studies have suggested that Hispanic and African-American populations may be at greater risk than Europids. Over 80% of patients with moderate to severe OSA go undiagnosed. There has long been a recognized association between Type 2 Diabetes and OSA, and there is emerging evidence that this relationship is likely to be at least partially independent of adiposity. Cross-sectional estimates from clinic populations and population studies suggest that up to 40% of patients with OSA will have diabetes. Polysomnography-dejined OSA and Type 2 Diabetes: A study of French men referred for assessment of sleep showed those with OSA (AHI 10) were significantly more likely to have impaired glucose tolerance (IGT) and diabetes than were those without OSA. The Sleep Heart Health Study showed a significant association between oxygen desaturation during sleep and elevated fasting and 2-h plasma glucose concentrations during an oral glucose tolerance test (OGTT). The severity of the OSA was also associated with the degree of insulin resistance after adjustment for obesity. The Wisconsin Sleep Study (n = 1387) showed a significant cross-sectional association between OSA and Type 2 Diabetes for all degrees of OSA. Among those with diabetes, sleep duration and quality have been shown to be significant predictors ofHbAlc. Some studies of the effect of CPAP treatment for OSA on carbohydrate metabolism have shown improvements in insulin sensitivity, glycaemic control and HbAlc. There are a number of proposed causal pathways linking OSA with Type 2 diabetes. There is evidence that the physiologic stress imposed by intermittent hypoxia and/or sleep fragmentation may be involved in the pathogenesis of insulin resistance via one or more of the following biological mechanisms: 1) Sympathetic nervous system activation - the sympathetic nervous system plays a central role in the regulation of glucose and fat metabolism. OSA has been shown to increase sympathetic activity not only during sleep, but also when subjects are awake. Sympathetic activation is thought to be predominantly a result of nocturnal hypoxia. However, the repeated arousal from sleep that follows each obstructive breathing event is likely to exacerbate this effect. 2) Direct effects of hypoxia - the temporal alliance between oxyhaemoglobin desa­turation and arousal from sleep in OSA poses the challenge of segregating their independent pathophysiologic effects. Recent work in normal human subjects, however, has shown that sleep disruption and intermittent hypoxia can each decrease insulin sensitivity and worsen glucose tolerance. Furthermore, animal data show that intermittent hypoxia during waking hours (i.e. not accompanied by arousals or other sleep disturbances) leads to a reduction in insulin sensitivity. 3) Hypothalamic-pituitary-adrenal (HP A) dysfunction - hypoxia and sleep fragmentationmay lead to activation of the HPA axis and excessive and/or an abnormal pattern of elevation of cortisol levels with the potential for negative consequences on insulin sensitivity and insulin secretion. 4) Systemic inflammation. OSA patients have been shown to have higher levels of inflammatory markers as well as showing increased monocyte and lymphocyte activation with evidence that these changes are independent of adiposity. These effects are thought to be largely due to the effects of intermittent hypoxia, but sympathetic activation probably also plays a role. A recent study examined selective suppression of slow-wave sleep (a phase of sleep thought to be the most restorative stage) in healthy young adults, without affecting sleep duration or causing hypoxia. The intervention markedly reduced insulin sensitivity and led to an impairment of glucose tolerance. Seems like fairly substantive rationale, in my uneducated opinion. Thoughts?

I don't believe any new service records were found in any of the cases we are discussing in the threads.

Thank you. I appreciate the response. The thing I am still stuck on is how can a NOD for a current decision can refer to an older decision and ask for adjustment, without actually being a CUE. I'll read and absorb more till I catch on. Thank you for the kind tone and demeanor in your response.

Perhaps, I don't understand what I've read regarding NODs & CUEs. If I may let me provide my real life example to better explore you point and make sure I understand correctly. Here is my real-life example. I exited the Army in 1997, with a medical discharge. I half-heartedly participated in the process and was given 0% for range of motion, left ankle, and 10% for Asthma. I claimed residuals of fractures for for both feet, which were denied service connection. I claimed nothing else. Fast forward to today. I looked in my C-file and noticed that my entrance and exit hearing exams showed quite a bit of hearing loss. I have hearing exams in the that show STS loss, declare "works in hazardous noise environment" and the exit exam shows on score above 40 db, which is hearing loss by definition (likely 0%). If I file a claim to day, they go on C&P Exam next month, and am then rated at 0% back to today are you suggesting that I could file and NOD stating the effective data should be 1997 even though I did not file a claim back then? I believe this situation to be analogous to the example we are discussing because even though there was a claim in the 80's... A NOD was never filed for it, and it become final. I am not trying to be confrontational. I am merely trying to better understand the process. I also suspect this may be a moot point, if one files a NOD alleging the incorrect data based on an error. They make take that as a CUE request and process it that way anyway?

I would not think so.

The only issue I see with this is that a claim initiated a year ago can only have an effective date of the beginning of the intent to file. As the the claim was awarded as of that date, I am not sure what NOD will do. The problem is the issue isn't with the current claim. The current claim was won. No one disputing the rating.... not one is even disputing the award. What is being said here is, "my other claim from over 20 years ago should have been approved.". I don't believe this issue can be addressed with a NOD on the most recent claim. I think this would simply was just eat time. I would suggest exploring the CUE which is the only way to adjust a final decision and earlier effective dates (EED) are the easiest to CUE. I just had two cue'ed EEDs from 5/11/98 back to 5/11/97. I didn't even have to file anything as soon as they were pointed out they were fixed by them. In my uneducated opinion, I would suggest filling a CUE stating the following (simple overview): Clearly the there was a CUE here as the my recent claim was awarded with no new evidence. Thus if the evidence was sufficient now, it was certainly sufficient then. Given the time frame and potential award. I would consider a lawyer/advocate like John Dorle. This could be substantial retro. Just my thoughts.