FMFDOC25

VSO's aren't perfect, but they do know what forms to use to submit a claim, NOD, etc. When did you get discharged? Is this your first ever claim that you submitted? What did you claim?These are the questions that will give a baseline of what are the next steps to take. The other question I have is did you already have a service-connected disability? Reason being is if you did have a service-connected disability after you got out, you may be able to use Secondary-Service Connection if your service connected disability caused or aggravated a current disability.

My interpretation of the all of the medical evidence presented leans more towards what the Ratings Schedulars tend to do. Because Pyramiding of disability conditions is not allowed, such as mental disorders, they may end up service-connecting PTSD with Panic Disorder and Agoraphobia. Either way, the rating criteria is the same for all mental disorders, so I wouldn't be surprised if they combined it like that. It looks like the evidence weighs in your favor for a 70% or 100% rating, as follows: 100% rating: This rating will have the majority of the following circumstances and symptoms: The Ability to Care for Yourself: This individual cannot take care of himself at all. Constant or near-constant hospitalization and one-on-one supervision is required. Medications: This individual requires psychiatric medication at all times. Symptoms: Some or all of the following symptoms will be present. – Regular or constant delusions or hallucinations and the inability to tell fact from fiction – Completely inappropriate behavior (like drooling, mumbling, shouting, etc.) – There is constant danger of hurting self or others (including suicidal tendencies) – Significant memory loss, including not being able to remember names of close friends, family, or self, and other important information – The individual cannot understand the idea of time or place – The individual cannot properly reason, think or communicate logically – Constant anxiety, fear, suspicion The Ability to Work: This individual cannot work at all. Social Relationships: This individual cannot participate in any relationships. In other words, they cannot interact or build a relationship with another person. Family members may care for them, but it is only a one-way relationship. They cannot seek, invite, or encourage any relationships. 70% rating: This rating will have the majority of the following circumstances and symptoms: The Ability to Care for Yourself: This individual cannot take care of himself most of the time. He is in the hospital or a care facility or is being taken care of by family members all of the time, and requires one-on-one supervision 50% of the time. This person cannot take care of his own personal hygiene. Medications: This individual requires psychiatric medication at all times. Symptoms: Some or all of the following symptoms will be present. – There is the regular possibility of hurting self or others (including suicidal tendencies) – This individual often cannot communicate logically – This individual is actively psychotic, but may have intermittent contact with reality – Obssessive-compulsive behavior that causes repetitive physical actions that interfere completely with daily necessary activities – Severe, constant anxiety – Mood often changes radically, without warning. – Almost constant severe depression or panic, with the inability to function at all in stressful situations – This individual cannot control impulsive actions like anger, violence, etc. – Often disoriented to time and place The Ability to Work: This individual may not be able to work at all or may be severely under-employed (such as a former intelligence analyst now working part time as a custodian). Social Relationships: This individual cannot participate in any relationships most of the time. In other words, they cannot interact or build a relationship with another person. Family members may care for them, but it is normally only a one-way relationship. They cannot seek, invite, or encourage any relationships the majority of the time. The only problem I see is the way the Nexus of opinion was written. It doesn't state "due to" (100% probability); "more likely than not (greater than 50% probability); or "at least as likely as not"(equal to or greater than 50% probability) incurred in service. I wouldn't be surprised if your claim goes to Preparation for Decision, then back to Gathering of Evidence so the correction can be made. Usually when that happens it takes a few days up to two weeks for the examiner to make the correction then it will to back to Preparation for Decision. It's just an addendum the examiner will have to do. You'll see it in your VA notes. Best wishes on your claim.

On the dental C&P what does the C&P examiner's nexus state? You only need the examiner to state "at least as likely as not" (equal to or greater than 50% probability) was due to service. If it's a direct-service connection claim. On the other hand, if it's a secondary condition being claimed did the examiner state "at least as likely as not" (equal to or greater than 50% probability) was due to service connected disability? Also look for "If you see that and a rationale substantiatiating the claim. You're good. Now, if the examiner did not provide a rationale with an unfavorable nexus such as "not at least as likely as not" (less than 50% probability) or "not due to" (0% probability). Point that out there was no rationale provided by the examiner on your exam for your appeal because that would make that C&P Exam inadequate, resulting in a remand . The same could be said if a rationale is not provided for a favorable nexus, it'll result in a remand, which delays the appeal process, but instead the court details instructions of what needs to happen to proceed with your case at a later date. This gives you some time to find more inaccuracies or obtain a favorable nexus of opinion from another physician, if you haven't already obtained one. (An unfavorable nexus and poorly provided rationale vs a favorable nexus with a well-written rationale=a tie...and a tie goes to the veteran.) You're not wrong if you know what happened or didn't happen during your C&P Exam....YOU WERE THERE!! Whatever inaccuracies you witnessed have it documented in your notes and question the competency of the examiner. It's not going to hurt you because if the exam is ruled to be inadequate, another C&P exam will need to be done or the court will instruct the examiner to provide their rationale and if it's still not adequate enough? Then I have no idea WTF they're doing. lol. I'm confused about the Sleep issue. Was a sleep study done? I mean were you actually hooked up to the sleep study wires and had you sleep without a cpap and then had you sleep with a cpap? Yes or no? If so, what does the report say towards the end of the sleep study and what was the recommended diagnosis and treatment? Now if you just had a sleep consult, yet the examiner stated that a sleep study was already on record?then that would raise concern, because the examiner sounds like he or she was lying. I think that would be a reason of a doubt, to conclude that exam would be deemed inadequate. Call out mistakes out, if you feel their necessary, but be prepared with clear and unmistakable medical evidence. The ratings scheduler has to use any medical evidence pertaining to your claim or claims. Hope this helps explain some things. Best wishes on your claim.

Since you alluded to having 10% service-connected CAD: Sleep Apnea and Hypertension would be secondary conditons that can boost your disability rating depending on your medical history and medical evidence. SEE REQUIREMENTS FOR SECONDARY SERVICE CONNECTION TOWARDS THE END OF THIS POST. If you have been diagnosed with OSA and are using a CPAP machine. The answer to part of your question is yes; Sleep Apnea is associated to or linked to Coronary Artery Disease. Claim it "Obstructive Sleep Apnea as Secondary to Coronary Artery Disease. If granted, Obstructive Sleep Apnea will be rated at 50%. Here is a study that finds sleep apnea common in patients with coronary artery disease. Wien Med Wochenschr. 2010 Jul;160(13-14):349-55. doi: 10.1007/s10354-009-0737-x. Sleep apnea is common in patients with coronary artery disease. Prinz C1, Bitter T, Piper C, Horstkotte D, Faber L, Oldenburg O. Author information Abstract Sleep-disordered breathing (SDB) has a prognostic impact in patients with cardiac diseases. We included 257 patients with preserved left ventricular function and angiographically proven coronary artery disease (CAD). All patients underwent cardiorespiratory polygraphy. In 251 patients high-sensitive C-reactive protein and fibrinogen were measured. SDB was documented in 188 patients (apnea-hypopnea-index [AHI] 16.4+/- 1.9/h): 58 patients presented central sleep apnea (CSA) and 130 patients obstructive sleep apnea (OSA). All patients (73%) with SDB had higher blood fibrinogen levels than those without SDB (p = 0.01). We found 197 patients with CRP-values below the cut-off of 0.5 mg/dl (group 1) and 54 patients with no active infection but CRP>0.5 mg/dl (group 2). Severity of SDB was significantly higher in group 2 (p = 0.01). SDB has a high prevalence in CAD patients and seems to be associated with chronic inflammation, which may be linked to CAD progression and/or acute coronary events. PMID: 20694765 DOI: 10.1007/s10354-009-0737-x [Indexed for MEDLINE] Here is another study that links hypertension and CAD. Hypertension and coronary artery disease: cause and effect. McInnes GT1. Author information 1 University Department of Medicine and Therapeutics, Gardiner Institute, Western Infirmary, Glasgow, UK. Abstract NATURE OF RELATIONSHIP BETWEEN HYPERTENSION AND CORONARY ARTERY DISEASE: Epidemiological data indicate a strong and consistent link between hypertension and coronary artery disease. This does not mean that hypertension is the cause of coronary artery disease. Less than a quarter of the risk of developing coronary artery disease can be attributed to raised blood pressure. Furthermore, in individuals, hypertension is only weakly predictive and hence blood pressure cannot be relied upon to identify those with a particularly high risk. EFFECT OF A REDUCTION IN BLOOD PRESSURE ON CORONARY ARTERY DISEASE: The results of outcome trials, largely in men with mild to moderate uncomplicated hypertension, demonstrate that a modest short-term reduction in blood pressure confers a reduction in coronary artery disease events of about 16%, against the expectation from observational studies of about 22.5%. Explanations for the apparent shortfall include the putative theory that metabolic effects of the drugs used in the trials (mainly thiazides and beta-blockers) offset the beneficial effect of the blood pressure reduction. However, from consideration of epidemiological findings, it is clear that a large proportion (over 75%) of events in hypertensive patients is unlikely to be preventable by managing the elevated blood pressure alone. TREATMENT CONSIDERATIONS: Since arterial pressure interacts in a more than additive manner with coincident coronary risk factors, treatment should be initiated on the basis of overall risk and directed by predictors of myocardial infarction. In addition to a sustained level of blood pressure, these predictors include established coronary artery disease, older age and cigarette smoking. BEYOND BLOOD PRESSURE REDUCTION: Whether metabolically neutral antihypertensive drugs can reduce the shortfall between expected and observed benefit remains uncertain. However, some newer agents (angiotensin converting enzyme inhibitors and calcium antagonists) appear to have an effect on vascular structure and function that is independent of blood pressure reduction. If these advantages are confirmed in clinical trials, these drugs offer the prospect of a much greater impact on coronary artery disease than currently obtained. This study suggests that hypertension does not cause CAD, but moreso, CAD causes hypertension. Claim it "Hypertension as Secondary to CAD." Depending on the history of your blood pressure here is how hypertension is rated. Your rating depends on your blood pressure reading. Per § 4.104-10 Code 7101: If your diastolic pressure (bottom number) is 130 or higher: 60 percent rating If your diastolic pressure is 120 to 129: 40 percent rating If your diastolic pressure is 110 to 119, or your systolic pressure (top number) is 200 or higher: 20 percent rating If your diastolic pressure is 100 to 109, or your systolic pressure is 160 to 199: 10 percent rating If you get the highest ratings granted for Sleep Apnea and Hypertension here is the VA MATH: 10%+50%60%=82% rounded down to 80%. Requirements for Secondary Service Connection: 1. Current Service-Connected Disability 2. Current diagnosis/disability 3. Nexus of opinion linking #1 and #2. You only need a doctor to say #2 is being caused or aggravated "at least as likely as not" (equal to or greater than 50%probability) due to #1; and provide medical rationale to substantiate your claim. I wish you well.

I concur with broncovet, pyramiding is not allowed, but secondary conditions can be caused or aggravated by PTSD and PTSD medications that will increase your disability rating. Each secondary service connected disability gets its own separate rating if I'm not mistaken. For example: Sleep Apnea is associated with psychiatric conditions. Therefore, if you develop Sleep Apnea or have developed sleep apnea you can secondary service connect it secondary to PTSD medications. PTSD doesn't necessarily cause it, but medications used to treat PTSD can due to many of them having sedative/drowsiness effects. Sleep Apnea is rated 50% with use of a CPAP machine. In VA Math, 70%+50%= 85% rounded up to 90%. Sorry I got sidetracked. Where were we? Oh yea...from my understanding, if a veteran is 50% or more PTSD is a disqualifier for a law enforcement occupation. But, that's left up for debate. I would suggest to begin individual or group therapy if you haven't been going. Anger Management classes are offered through the VA. I imagine this incident put a strain on your friendship ,if not ended it. I wish you well.

You're not wrong and I don't diagree with you. But, I found it's slightly easier to Secondary Service Connect OSA. If there is no medical evidence in SMR of Sleep Apnea it'll be a harder road to get it granted as a Direct-Service Connect. Most VA Dr.s won't provide a nexus of opinion or fill out the required DBQ's, some are willing to do it, if they know how. Most civilian docs don't know the VA's requirements, so the burden falls on us as veterans to educate a private physician on filling out the DBQ's, what the nexus letter is and how it needs to be written to provide a favorable decision from a ratings scheduler. Although, there are private physicans that know and understand what the VA requires, it'll cost a veteran hundreds if not thousands of dollars and even then it's not a guarantee that a favorable decision will be granted. Secondary Service Connecting OSA is probably the best way to service connect OSA for an after-service diagnosis of it. PTSD or other mental disorders (Depression/Anxiety,etc). This is an actual VA study that was done and it was used to provide rationale for my secondary service connection from a C&P examiner. https://www.ncbi.nlm.nih.gov/pubmed/16335330 Chronic Sinusitis, Deviated Septum,and Chronic Rhinitis are some conditions that are associated with Sleep Apnea also. These are just some conditions off the top of my head, I don't claim to know all of them. TO SECONDARY SERVICE CONNECT: 1. Have a service-connected disability 2. Current diagnosis/disability of Secondary condition 3. Nexus of opinion stating the likelihood of link to military service and rationale; such as medical studies, etiology of condition. An example would be- I am so and so doctor with X-number of years experience in general or specialty practice. After reviewing all pertinent medical records of Mr. Veteran. The veteran has had a sleep study administered that confirms he currently has Obstructive Sleep Apnea. He has been prescribed and issued a CPAP Machine which he uses when he naps during the day and when he goes to bed at night. It is in my opinion the Veteran's Sleep Apnea is ["due to" (100% probability); "more likely than not" (greater than 50% probability); "at least as likely as not" (equal to or greater than 50% probability) is linked to [service-connected disability]. {These are the three phrases that MUST be in the nexus for a favorable decision.} Rationale: A study conducted in 2005 titled "Association of psychiatric disorders and sleep apnea in a large cohort" found that psychiatric conditions have a comorbidity to Sleep Apnea. Refer to attached study.https://www.ncbi.nlm.nih.gov/pubmed/16335330 In addition, I have filled out the necessary Sleep Apnea Disability Benefits Questionnaire.

Welcome to the forum! Persistence and Patience are key to helping yourself. You mentioned the trauma you witnessed and physical injury that occurred, I imagine, in-service. It sounds like you've been suffering from symptoms of PTSD for decades, as you alluded to. You stated you are usually the strong one, don't worry you don't have to be anymore. Only we veterans know what we've gone through, therefore you will get the unconditional support that you need from other fellow veterans. Allow me to tell you my story: I tried to deal with my issues on my own and guess what? It didn't friggin work out either. It took almost losing my 2nd wife and our son for me to seek help from the VA for PTSD. I went untreated for about 10 years before I asked for the help. I was only service-connected with 10% PTSD and 10% L Knee pain. I thought that was it and that was that. Yet, I was experiencing more serious symptoms of PTSD. In 2007 when I got out, I was a freaking train wreck, I had just gotten a divorce from my first wife, I drank myself to oblivion on a number of occasions, my parents and other family members didn't know what to do with me, I was bouncing around from family and friends places, I vividly had nightmares of my trauma, I'd isolate myself, I was withdrawn. I contemplated committing suicide on a number of occasions. I just wanted to die so I didn't have to deal with my crap and I didn't want anyone to have to deal with me. How I managed to stay employed was beyond me. I bounced around from job to job because I couldn't deal with how annoying civilians are alot of the times. You get the idea. So, long story short. I went to my local VA and began my journey to help myself. By no means, is the VA perfect, but the treatment I received, literally saved my life. If you are not already service-connected for PTSD or another mental disorder, physical condition/disorder, then here is what you will need to do. 1. Go to the nearest VA facility and ask a front desk clerk if you can speak to a patient advocate. Tell the patient advocate you are seeking help becoming a patient there. 2. When you go through the process, you will be assigned a Primary Care Provider. When you go; there are alot of questions that will be asked, so be prepared to take a copy of any medical records, xrays, MRIs, CT scans, Lab Results from your private doctor or doctors. If you happen to have been fortunate enough to obtain a copy of your Service Medical Record it's best to bring that too. This will help your Primary Care Dr. address any chronic illnesses. It will help the dr. point you in the right direction. I would advise to address the most important issue first, which it sounds like it is going to be symptoms of PTSD or another mental disorder (I'm not a doctor, so I can't make any diagnosis.) This is all educational information for you to use at your convenience. 3. You can learn more about PTSD here if it is determined by a professional mental health doctor you have it. https://www.ptsd.va.gov/public/index.asp 4. If it is determined you and are diagnosed with PTSD or another mental disorder, you will need to start the paper trail for about 1-3 years. The goal is to build clear and unmistakable medical evidence for when you decide to make a claim for PTSD. I know 1-3 years seems like a long time, but like any Vet that has battled the VA Ratings Schedulars and Appeals and got a claim granted; medical evidence is the key component to any claim. You will also need to do your homework for what you are trying to claim. 5. Post-Service Claims: If you were not service connected for any condition after your discharge? To DIRECT-SERVICE CONNECT there are three requirements- 1. A documented in-service event. From my understanding, service records, medical records, and what's is called lay evidence; such as, Buddy Statements that confirm the in-service event qualify to substantiate your claim. 2. A current disability of what occurred in-service. 3. A nexus of opinion. A "competent medical doctor" can only provide a link to service-connection of the disability being claimed. Basically, the doctor must say that your disability developed because of military service and a rationale must be included. (We can go in depth at a later time, if you would like.) This is alot to process so, take your time. Remember "Persistence and Patience".

I may have a clearer answer why your right knee claim was denied. According to the info you provided, it appears you attempted to DIRECT-SERVICE CONNECT. Which 99.9% of the time will get denied for what the VA states did not occur in-service...BUT...there's another way you can get it granted. In a previous post, you mentioned your right knee is fubar because of your left knee. Here's where you may be able to get your right knee instability granted. Did you or have you attempted to SECONDARY-SERVICE CONNECT your right knee to your left knee? Secondary Claim These are claims for disabilities that developed as a result of or were worsened by another service-connected condition. In other words, it is recognized that a service-connected disability may cause a second disability. This second disability may not otherwise be considered service-connected. The requirements to getting a Secondary Claim granted are as follows: 1. Existing Service Connected Disability( check yes...your left knee.) 2. Existing Disability or Disease(Check yes...right knee instability.) 3. Nexus of opinion linking the service-connected disability that's causing or aggravating your current disability to your right knee. I would suggest you attempt to re-claim it as: 1. "Right Knee Instability, Secondary to [your left knee condition]" Also, did the Dr. that provided the IMO have either of these key phrases the VA looks for in Nexus opinions? 1. “is due to” (100% sure) 2. “more likely than not” (greater than 50%) 3. “at least as likely as not” (equal to or greater than 50%) 4. “not at least as likely as not” (less than 50%) 5. “is not due to” (0%) Give it one more shot. Don't give up.

I apologize if this is going to be a long-winded explanation. I'll get to my question at the end. I was on barracks duty during my time in service. While on duty, I was physically assaulted (Beat up) by a belligerent resident that was supposed to be a buddy of mine. I was repeatedly punched for what seemed forever ;to my head and face. It took other residents to pull him off me and the MPs were called. I sustained a bloody nose, cut lip, and bruising all over my face.I had submitted an incident report with them and pictures were taken by the MPs. I didn't go to medical the next day because I was embarassed and was still dazed and confused of what had happened. I don't recall the exact year, but it was the summer of 2001 or 2002. The two questions I have are, as follows: 1. Where can I obtain information of that incident in 2001 or 2002? 2. Can I claim TBI for that incident, especially since I am service-connected PTSD?