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Good morning hadit, I have both ptsd and TBI and believe my diagnosed sleep apnea (mixed sleep apnea, with both central and obstructive sleep apnea) has been directly caused by my ptsd and TBI. I am not overweight, have no medical issues of the throat or the respiratory system that would cause it. My question to you all is if I want to file sleep apnea secondary to either of this conditions which one should i file it secondary to? I've found much more literature tying obstructive sleep apnea to ptsd but also found literature that ties both obstructive sleep apnea and central sleep apnea to brain injuries as well. Is it possible to file it secondary to both?

Good Afternoon Team, Short back story/timeline: Left Active Duty: August 2015 Diagnosed with Sleep Apnea February 2016 (6 months later) Submitted claim in May 2016 with my evidence: Sleep study DBQ In service complaint of snoring exerpt from my medical record Favorable C&P Exam opinion (at least as likely as not...) VA Denied my claim in August 2016 I did nothing because I didn't think I could come up with any other evidence Fast forward to last year..... I scratched some pennies together and paid for an IMO, then submitted the letter via a supplemental claim. I was awarded SC for sleep apnea at 50% within a month of the VA receiving my claim. Success! Here is the link to that process in the research forum: So here is my line of thought... Can I use HLR to fight for an earlier effective date, or do I have to use CUE? I mean, the VA had everything it needed to make the proper rating the first time (In-service event, nexus from the C&P doc, current diagnosis...). I have a hard time with the fact that I had to pay an outside doctor just to agree with the C&P exam doctor. Why would the rater place his/her opinion over the VA's own doctor? Shouldn't the benefit of the doubt have gone to me? From what I understand, I can't CUE the benefit of the doubt anyway. Since I am within the appeals period of the supplemental claim, I'm thinking the easiest path may be to request HLR in order to ask them to CUE themselves on the 2016 decision. Is that possible? I'm just trying to avoid CUE if I can, since it's mainly a "last resort" type of measure.

Hey all, First off, love this page it has been extremely helpful! Background: currently at 90% / 70-ptsd, 50-migraines, 10-iritis, 10-tinnitus, and I’m in the running for 100 at the moment. Current day: Was content at 90 but after all these years I have finally come out about my MST when I was in the infantry. Still working stuff out on that end as this is still fresh... Anyway, I submitted a claim for sleep apnea because of the MST. I submitted the following: picture of CPAP machine I use in my house, nexus statement from issuing doctor, Nexus statement from other doctor stating the sleep apnea is due to trauma from MST, copy of sleep study confirming I have sleep apnea from doctor listed above and buddy statements as well as the formal submission paperwork of my MST to three levels of my chain of command, NCO, O3, O5 etc... Wrap this all up with a successful expedited hardship approval and you now have me waiting for answers. Well today (a few moments prior to writing this) I found out I am getting a C&P exam for this...I almost feel like this is a slap in the face...I mean how am I to go up to that examiner and explain all this when I literally gave it all to them... Has anyone been in my shoes before??? Thank you all.

After Denials for OSA both direct and secondary to PTSD, this spring I decided to spend the money on a IMO and do the claim right. I contacted Dr. Anaise and was told to send all my records, decision letters and $1500. After about a week I was emailed with a final IMO report that was around 40-50 pages. It was excellent & well researched. Within 6 weeks of submitting the IMO with a supplemental claim OSA secondary to PTSD was approved. Yes IMO's dont guarantee anything and they can be expensive but they are definitely worth it when you have been denied already and have nothing else to submit and someone like Dr. Anaise will always outweight the NP the VA usually has doing exams.

Moderator, you might want to Pin this somewhere, as this seems to be a recurring trend. I have given out this information to others, but I will post it here so that others can find it rather than searching through the forum. First and foremost, claiming and getting sleep apnea secondary to PTSD or Mental disorder is not easy. I have personally seen more lost than won, however, it can be obtained and I myself have personally received it. If you had sleep apnea diagnosed while in active duty, it is usually a slam dunk........for the rest of those trying to get it, it could require a lot of work. I suggest trying to get it both direct and secondary service connected. It is easier to get sleep apnea as a direct service connection obviously, however, most Veterans do not get it diagnosed while in service. Best way to get that resolved is through buddy statements. I suggest getting 3-4 (I personally had 7-8) or more. Do not have them only say that they saw you snoring.......that is great and all, but that is not a symptom of sleep apnea.......it is incidental. They would need to say that they saw you gasping for air, choking, etc. Preferably roommates. If you were deployed, it would be easy to have many people saying that they saw/heard this as you would have more than likely been in an open bay setting at some point in time. You can also have your spouse write up a statement. This all needs to be during active duty periods of times and dates need to be included. M21-1 reference III.iii.2.E.2.b "Types of Evidence VA May Use To Supplement or as a Substitute for STRs" allows for buddy statements to act as STRs for medical evidence.........if they are certified "buddy" statements or affidavits.............having them written on VA Form 21-4138 solves this issue as it has the appropriate verbiage written near the bottom. Under M21-1 reference III.iii.1.B.7.a and 38 CFR 3.200, it meets the certification criteria..........problem solved. From my experience, getting all of the buddy statements needed can take longer than you originally anticipate....plan ahead. Now, for secondary criteria. Have you ever been diagnosed with alcohol abuse (it is frequently written as "ETOH")? If so, has it been attributed to your mental disorder or did it exist prior to that and is it considered willful? If you have been diagnosed with alcohol abuse, and it is attributable to your mental disorder, guess what, alcohol consumption is attributable to sleep apnea. would suggest that you start doing your own academic research. You might be able to locate peer-reviewed academic journal articles (those are the types of articles that you want to submit) through https://www.researchgate.net/. If not, another alternative is using a college database to search academic journals through. Ah, but you need to be a college student to use the database to search academic journals through. One might make an argument that you could register for classes at a local community college (you can even register online nowadays without even stepping foot on campus) and even register for "late start" classes, and have access to the aforementioned database immediately (hint hint, look in the academic journal Chest); one could easily find within a 60 minute search at least 5 appropriate and recent journal articles clearly establishing a link between specific mental disorders and sleep apnea; there is a clear link between PTSD, anxiety disorders, depression, and especially schizophrenia. One might make an argument that you could simply then disenroll from the classes that you enrolled in by the date specified in order to get a full refund, thereby being charged nothing. Save the academic journal articles as pdf files, and create a work cited page (bibliography) for them in APA format (google is your friend.) You now have a choice........... Submit your claim with the buddy statements, mental health notes from a private provider, and evidence that you have and go with either a VA exam or vendor exam (whichever is given) or you can get an IME and IMO from private providers. If go the latter route, I would schedule one with a sleep specialist, why, because sleep apnea is their specialty. Pulmonologists also fall within this scope as well, though I suspect that you will have better luck finding a sleep specialist believing there to be a link between mental disorders and sleep apnea. You will get a Sleep Apnea DBQ and an IMO. Make sure that you have your C - File first as an examiner is required to have access to it and state that they have seen it on the DBQ for it to acceptable proof to the VA. I would also get one from your psychologists/psychiatrist (Make sure that they are a psychiatrist or a psychologist.....if a psychologist, they need to be PsyD or Ph.D., or under the observation of a Ph.D.). Make sure before you solicit those medical opinions, that you acquire "buddy statements" from 3-4 (or even more) people with whom you served. Roommates would be best, or people who slept in close proximity to you.........again, this is only if you believe that sleep apnea developed while you were in Active Duty service. Make sure that they are written on VA Form 21-4138. Make sure they say that they witnessed clear symptoms of sleep apnea i.e. gasping for air, choking sounds, moments where they visibly or auditorily could determine that you ceased breathing etc. Remember, you will want the sleep specialist and the psych professional to have your academic journal articles and buddy statements. Once you have all of them, solicit your medical opinions from the two aforementioned providers. Ideally, you would love for the IMOs to say that they believe that you could be both direct service connected for sleep apnea or secondary due to mental disorder, possibly even say that the mental disorder and sleep apnea aggravate one another (which there is medical evidence to support.) If you opt to go the route of getting the private IMO and IME, you will obviously submit those with your claim, and all medical records from private providers pertinent to sleep apnea and your mental health treatment, buddy statements, academic journal articles, and a nicely written statement written by yourself on a VA Form 21-4138 talking about the issue at hand and summarizing everything concisely. Mention everything that you are providing that you wont to be considered for the claim, and when the issue first manifested.

A little background first on this specific claim to provide greater context for the readers. I had no idea that i had OSA until i got married and through the years my wife has told me about how i would snore really loud, stop breathing at night, choke, etc. pretty standard stuff for anyone that has it. I had buddies in the Marine Corps who told me the same thing after our first deployment, but i had always chocked it up to my dad snored so i snored, the stopping breathing thing was weird but i was 18/19 so your health isnt a primary concern and BAS is only for bones sticking out. I got out in 2006 and didnt make a claim for OSA until 2016. First i talked to my primary care then was referred to a VA pulmonologist. He ordered a sleep study and the VA fumbled it sending me to a private facility and did a in home test. When the results came back i saw in my VA health record the Pulmonologist was terse with his message saying he wanting a in facility sleep study so a month later i did mine at the VA overnight. I was diagnosed with Mild OSA and given a CPAP. When the CPAP arrived i spent a month trying to get it to work but every morning it would show only 45-60 minutes of time. I have nightmares at night, some i remember some i dont but would rip off the mask or when i woke up would be so worked up i didnt put it back on. I do cycles of trying it for awhile and stopping for awhile, giving it a chance because my wife is worried about the OSA and its health effects. My claim history was this, as i stated i made my first claim in 2016 and was denied. I reopened the claim (when that was still an option in 2018) and was denied again. What i submitted was bascially the VA medical record showing that i had it, that i was ordered a CPAP and sworn statements by myself, my wife and buddies in the Corps that stated they saw symptoms in 2003-2006. I had NO nexus or medical proof that it began in service I made a mistake in 2019 when it was denied again and NEVER filed a NOD as i kindof gave up when that and other new claims for increases were denied, but I DID make a intent to file back in July 2019. I was out of the VA regulation changes loop and didnt know that they had gotten rid of reopening and moved to the Supplemental evidence route so in February through April i decided to really focus on making a quality claim since my 2016/2018 claims were more shot in the dark hoping that the VA would just grant it. I went to specialists in the field for the claims i was making and got updated diagnosis of symptoms and effects, got my sworn statements (which in my opinion has more 'umph' than a buddy statement) more detailed in terms of observed symptoms, timelines and effects upon my life as well as i went out and got two IMO's. The first IMO was for PTSD from Dr. Elaine Tripi in Michigan whos IMO got the VA to drop their attempt to reduce my rating in 2015/2016 (and i suspect it was because her IMO made a case for an increased rating). In that IMO she detailed my history, current symptoms, etc as well as opined on how my PTSD affected my OSA symptoms and how it interfered with its treatment. I also got a IMO from Dr. Anaise who wrote a lengthy (near 50 pages) on how my OSA is aggravated by Tinnitus and PTSD and interferes with my ability to go to sleep, stay asleep and interferes with my treatment. When i submitted the claim (reopen was still available as an option on ebenfits) my new claims, increase and "reopen" were all lumped together as one big claim and sent off in April. As a sidenote whenever i send my claim i do so through ebenefits as well as fax AND send CERTIFIED MAIL WITH RETURN RECEIPT. i keep a copy of the USPS receipt with tracking, Cert Mail receipt and the return receipt and staple that together with my hard copy claim evidence in a folder for each claim ive ever made. The VA has a way of "losing" evidence and if you ONLY submit via ebenefits, regular mail and/or fax you cant prove they received it per say. This DOESNT mean they wont pretend they didnt get it but what it does is allows you to prove upon appeal that YES you did send it in the time window necessary for your claim AND that they did receive it because the return receipt shows Jim VArep did in fact get it on such and such day. So if you get denied its really important to look at your cfile after to see what evidence the rater actually looked at and if they dont have ALL the evidence in that file you can appeal on those grounds in conjunction with more evidence if necessary that X doctors exam or IMO proves your case, wasnt considered AND the VA had received it. So a few weeks after i submitted it, the VA sent me the normal letter stating they had received my claim for X,Y,Z New & increased claims but i didnt see anythign about OSA which was weird. a week later i got a letter from the VA saying that my claims for OSA were not new, had been denied previously and were not on appeal and gave me a list of options. I chose Supplemental Evidence since the IMO's were "new evidence" to be considered and met the criteria and it had been over a year since my denial so i couldnt submit a NOD and get the backdated effective date. This was my fault. One i gave up in 2019 and didnt file a NOD to hold my place and Two i didnt keep up to date with new VA regs regarding reopened claims, etc. Since that supplemental claim was received on 4/24/20 (todays date is 6/18/20) I have had two psych exams and two records reviews through QTC (private company the VA contracts to do DBQ/exams). The first pysch exam was related to my request for an increase for PTSD back in April and in May i had a NP contact me who was reviewing my med records for OSA and had follow up questions regarding my condition both current and past. In that conversation i talked about how i never went to go get checked because i never knew what OSA was at that time, thought it was normal to snore, etc., how BAS is frowned upon in the Marines for things like that, my history with it since i got out up to now and how my nightmares make me rip off the CPAP at night. I did ask her if she had seen my imo, other evidence and she said no JUST my medical record. I know examiners arent raters and all but I find it weird that VA will deny IMO's as valid if they dont "review veterans entire file" but will accept something from a examiner if its negative when only their VA med file is shared. Its great advice to always bring your evidence with you to a exam but given the current COVID situation ALL of my exams thus far have been telephone or video. I asked her what the exam was specifically for or what they asked her to examine and she said it was basically whether or not my OSA was service connected and occured in service. I do believe it was but i was making the claim as SECONDARY to PTSD and/or Tinnitus as an aggravation which she was unaware of. I fired off some angry messages via the IRIS system to the VA regarding this (no idea if they got included in my record or reached a rater since the only response i got was "thank you for contact us heres how to make a new claim"). Within the last 3 weeks i had a 3rd & 4th "exam". The third was a MD who was reviewing my records as well and asked alot of the same questions, she was also unaware this was a secondary claim for aggravation and had seen no evidence submitted or my entire file so i went through it with her again. The 4th exam was another psych interview which i was told was to examine my secondary claims to OSA, but knowing the VA i knew it was basically another review of my ENTIRE PTSD claim ive had as well. Vets should be aware that even if a exam is about something specific any evidence or statements made that can negatively effect an existing general disability & will be held against you. This was quite clear when he just asked about current PTSD symptoms and never ONCE asked about my OSA, etc. So i had to bring that up myself. VA.gov check claims hasnt been updated since a week after my claim submission. my OSA claim has said "we dont know your status" even now and my other new/increased claim stopped after "request for more information" (i.e. requesting new QTC exams). So ever few days i check that as well as ebenefits to see if any of the DBQ's show up in my blue button (none have but im guessing because QTC doesnt have to update the way in house VA does). Finally today i see on my disabilities list that OSA was granted secondary to PTSD for 50% bringing me to 90% with an effective date of 4/24/20. I know that this ISNT the same as a letter from the VA but i know someone who is a VA rater who has been giving me updates on my record so im 99% certain this ebenfits update is accurate. The takeaways are this. 1) Do the damn research and work the claim yourself, no VSO or rep is going to care as much as you do. You care about your case, they have 15,50,100 other vets whos cases they are working and even if they are a great VSO/rep they cant possibly give a crap as much as you do. dont hope the VA just "gives" you the rating you deserve make it so they cant NOT give it to you with the proper evidence. 2)IMO's are golden. I know not everybody can afford them, i couldnt per say and had to sell some things to come up with the $500 for Dr. Tripi and $1500 for Dr. Anaise, but they were well worth it, without them i definitely wouldnt have gotten my OSA approved. I think have both a MD stating both the phyiscal and mental nexus and a Psychologist stating the pure mental side gave it a one two punch. 3) Along with the IMO go to doctors/specialists in your area and get documented evidence of you issue, ask them to be detailed in the exam notes. I even emailed a couple time asking the doc (this wasnt for OSA but a different claim, but good general advice) asking them to update the notes to specifically include certain symptoms and effects upon quality of life. Having this helps alot, combined with IMO's its very difficult for a random NP to override their findings with one exam or phone interview. Remember the VA is military based in that the ranking officer rules. So if you only have a NP (nothing against NP's this is just how the VA works) from a urgent care saying you have OSA caused by PTSD or that your shin splints are 8/10 pain and they have a pulmonologist, MD or specialist say its only 1/0 and doesnt effect guess who wins. If you have two psychologists but yours has great bonafides and background and theirs has only been practicing for 5 years solely at the VA yours wins. Im not saying dont go to a primary care to document because youll only see a NP all evidence helps but be aware if they pull out a MD who counters that exams findings youre likely to lose. Because they will always want to lean to denial and if their person has more experience or is a specialist that will win over what you submit. Dont give them an option, and even if they do decide to rule against you, you can make a great appeal based on the fact they sided with their NP over a specialist in the field your making a claim for who knows more. 4) Never let claims die. Dont make a new claim until your ready to with great evidence (file a intent to file first though to preserve backpay/effective date) If denied make sure you keep a reminder about the NOD date and when you do file a NOD make sure that is certified mail with return receipt to prove you mailed it/VA received it before the deadline, because if you dont and they can make a case it was received 24 hours after the NOD deadline you lost you backpay date and possibly years of backpay. Now there are situations where claims die but if theres a opportunity to still make it on appeals hire a GOOD (there are alot of crappy ones) appeals attorney and move forward. I know they take 20%+ of your backpay but if you aent comfortable enough to navigate the appeals process its well worth it. 5) stay up to date on new VA regs, Hadit is a great source for this you dont want to be like me thinking that certain avenues are still open and they arent. If I had stayed up to date i wouldve been able to file earlier for the OSA and preserve YEARS AND YEARS of backpay now im only going to get 2 months. 6) I didnt do this for this claim although i should've and kept a diary of when i was using the CPAP, roughly when i ripped it off, data on how long i wore it, frustrations over not being able to wear it, info on my nightmares causing me to rip it off etc. years of diary entries wouldve been a help. I didnt need it in the end but if you cant afford a IMO things like this can help because theres NO SUCH THING AS TOO MUCH EVIDENCE. A diary is one of the key things that helped me win my migraines case. for months prior I kept a diary of my headaches and effects, then transcribed them into ebenefits health diary. I am not perfect at it but i now write as much as i can as often a i can in this diary about ANY service connected or possibly service connected illness (especially things that could be considered aggravated by a service/possible service connected disability). That way when you are making a claim or fighting a reduction you can pull out timestamped entries for months/years relating to it and it makes it harder for a rater to think you pulled this out your but last month to make a claim. A big thanks to everyone on HADIT. i did alot of research here through the years to help make my claims better and it worked Another big thanks to Dr. Anaise and Dr. Tripi for their outstanding IMO's that helped me win this.

I have a current claim for several injuries to include PTSD. I did some research and found out the best way of getting a rating for migraines is to have a diary through the VA of the migraines. For my PTSD which I got diagnosed through the VA in February, I'm taking Doxazosin (Nightmares), Hydroxyzine (Anxiety), and Sertraline (Mental Health). All of the medication causes headaches. However, the Sertraline only causes headaches within the first 2 weeks. I was going to wait until the claim was complete before filing for Migraines because I wanted to already have the rating for PTSD first so I can claim the migraines as secondary. But is there a way to still file for it now to still say it's because of the medication for the PTSD? Which route should I go or is there a better one? And should I talk to my VA counselor/medication doctor to get him to state that my migraines are caused by my PTSD and medications? I heard every time you file for a new claim, then everything gets re evaluated so it would be ideal if there was a way to get everything done now. Also, I did get diagnosed through the VA for Sleep Apnea back in February,. So, can I say that the migraines was also caused by the Sleep Apnea?

I currently have pending disability claims for several things to include PTSD and Sleep Apnea. I filed for my PTSD starting in December of 2019 and the Sleep Apnea starting around the same time due to the PTSD. I was tested positive for sleep apnea. This month, I just found out through the VA Biopsy that I have Sarcoidosis which now I'm on steroids for 2 months and other meds for 6. I learned through research that sleep apnea can be caused by sarcoidosis since sarcoidosis causes shortness of breath. If I file for Sarcoidosis and try to change things up by saying the sleep apnea was caused by the sarcoidosis, then the sarcoidosis may get denied seeing how I have nothing from service to relate which will deny the sleep apnea too. So, should I just file it by itself? If so, should I get an attorney to help me get it service connected? How can I get it service connected? I was going to wait until the current claim was done before filing. However, I just heard that whenever you file for something new, everything gets reevaluated so that's why I'm trying to do it now.

I was diagnosed with Sleep Apnea through the VA. I filed for compensation so I already know it’s going to get denied. After it’s denied, I need to know exactly how to do the supplemental claim for it. I’m already getting benefits for Insomnia which the underlining is Depression and Anxiety. So after the Sleep Apnea is denied, do I just make an appointment with my Sleep Apnea doctor and say, “Hello sir I’m just curious. I’ve been diagnosed with Insomnia which the underlining factors are depression and anxiety. Can you tell me what caused my Sleep Apnea?” Then hopefully he’ll say depression can cause it, Then I’ll say, ok I’ll go with that. Depression caused my Sleep Apnea. Thank you so much sir that’s all I needed. Everything that is said is recorded in my record anyway. Then from there I’ll file a supplemental claim and say the Sleep Apnea was caused from my depression. Right or is there another way?

I was awarded 30% service connected for sleep apnea when I left the military in 2008. In 2013, I was directed to and took another sleep study. It was found and the VA agreed that I needed to start using the CPAP. VA reviewed the evidence, agreed, paid for and I have been using the CPAP since 2013. In Sep 2019, during a review of my records, my representative informed me that using the CPAP meant that my SA rating should be 50% versus 30%. I filed an increase claim and was increased to 50% with an effective date of Sep 2019. Shouldn't the effective date be April 2013 when the diagnosis was received and approved? I checked and the 50% rating for using a CPAP was in place in 2013. I wasn't aware of the rating difference at that time, so I didn't file a claim at that time. I'm asking because I'm thinking I may be due some back pay...……….

Hello Vets! I read on one website concerning Sleep Apnea that in accordance with VA Adjudication Manual M21-1, Part III, subpart iv, chapter 4, Section D updated April 18, 2016; There is no longer the requirement to have been diagnosed with SA prior to leaving the military to receive a rating. First, I looked at the cited manual and Section D, does not pertain to Respiratory issues, Section F does. So I'm just looking for clarification. Clarence

Hello All, I am planning on filing a claim for sleep apnea, which was not diagnosed while I was on active duty, as well as cervical pain and Allergic Rhinitis, which were noted in STR's but not officially diagnosed until a few years later, despite continuous treatment for them by the VA. While there is some reference to sleep issues while I was deployed, and treatment records in service for the other two, I want to make my claim as strong as possible from the start. Having read through many of the posts here and elsewhere regarding the nexus to service connection, I believe I will need an IMO to connect the in service event (injury on deployment) and my current diagnosis for sleep apnea, since it was diagnosed about 9 years after I left active service. My spouse is willing to write a statement regarding the symptoms she has witnessed since I left service until my diagnosis, and I have had two sleep studies confirming a diagnosis of sleep apnea (both done at the VA, 6 years apart). I plan on trying for direct service connection (unlikely but worth a shot) as well as secondary service connection (I have other SC conditions, but only rated at 20%, to connect it to). The pulmonologist at VA said my chronic pain likely contributes to my sleep apnea, but I am guessing this is not affirmative enough language for the VA rater, which is why I plan on seeking an IMO, for all three issues I am claiming. My primary care Dr is at the VA, and tends to write in generalities, so I don't think she will be a good choice for writing the IMO/DBQ (she tells me I have to wear my CPAP or I will stop breathing or die in a car accident, but only writes in my chart that "CPAP is recommended"). I have been looking (unsuccessfully) online for doctors who specialize in providing IMO's, and have read about the ones reviewed here, but was wondering about another I keep seeing pop up in the google searches - VA Claims Insider. Seems like a one stop shop, but I have not found much information about them other than what is offered on their website and Youtube channel. Also, the idea of paying after a claim increase seems like a good option, since multiple IMO's can be expensive, but I would think this could present a conflict in the eyes of the VA, since the fee increases with the size of the award. Also, I'm not going to lie, I think it would be great to have someone go over my records and possibly identify issues that I can rightfully claim that I am just not aware of. That seems to be the service they also provide, along with IMO's. So, any guidance or reviews would be appreciated. I am pretty confident that I will need the IMO's. I just don't know where to get them without a potentially awkward first visit to a new Dr, "Hi, I know that we just met, but can you write this very detailed letter for me so I can get disability compensation. No pressure." Thanks, and thank you all for the great info on this site. P.S. - I do not intend for this to become a thread to bash one service over another, or to endorse any particular service. I would just like some honest opinions about any of the people you folks have used. The nexus letter seems to me to be the deciding factor in many of the BVA appeals I have read. Despite its importance, I have had difficulty finding solid info and advice about getting one. Also, I assume VA Claims Insider probably reads this forum, and I don't want to disparage anyone who is trying to help vets.

Hi all, looking for feedback regarding my progress and chances, along with any other suggestions. I served in the Navy from 1999-2005, Honorable discharge as a nuclear mechanical on subs. Sadly, like many I rarely reported medical issues while I was in, didn't want to hurt the command with absences. If only I knew then right? In 2015 I filed put my first claim in, Rhinitis (this was well documented inservice) sleep apnea, i had symptoms inservice that were documented but never diagnosed and hypertension secondary to OSA. I thought I had a good package, I had buddy statements and an IMO from Dr Ellis. Well the VA disagreed. They granted SC Rhinitis at 10% and declined SC for OSA and HTN. I applied for a denovo review and they upheld the first rating. I then let my 1 year expire and things ended there. A few years later my sinuses were getting worse. I saw an ENT who diagnosed severe sinusitis a deviated septum and polyps. We tried steroids and antibiotics and then went with a pretty complex sinus surgery. Post op several rounds of steroids and still have polyps. I currently use daily steroid irrigation. That sucks. My OSA of course was diagnosed with a sleep study, it was rated as severe and I use a CPAP daily. I strongly feel that the fact that I can barley breath through my nose makes it a lot worse. The diagnosis on all of these are unarguable. Its the SC that will be the battle. HTN: I have pretty severe HTN, it is controlled with 3 meds daily. The literature is pretty clear that OSA worsens HTN. And for what its worth, I don't use the VA for health care. So my packet: I had hoped to try the DRC process as, I am very lucky to have the resources to build my own claim. I used Bethany who is a PA at Valor 4 Vets to do my DBQs for Rhinitis /Sinusitis, OSA and HTN. She also wrote IMOs for each with literature cited. The least as likely then not phrase is there for every condition. I'm happy to post if it will help anyone. I also wanted an IMO from a doc with a little stronger CV so I went with Dr Aniase, I know he's been talked about here and like others have said the service was great. Also he is a former lung transplant surgeon, who has focused a lot on OSA so I thought that was a good fit. He put together a solid 65 page letter with a lot of literature and medical rationale that OSA is make worse by Rhinitis and that HTN is made worse by OSA. He went on to say that sinusitis is only caused by rhinitis and pointed out the rationale for increased rhinitis. I of course had all of my private medical records. I took these to my local VFW service officer on 4/17. I had no problem doing the claim myself by a DRC claim has to be submitted by a VSO. She tried to discourage the DRC process as it shifts the responsibility to the Vet and the VSO. I get that but I already have everything and hopefully wont need additional exams as I have my DBQs. She relented and took all of my compiled paperwork to submit. Well shockingly while her cover letter asked it to be processed as a DRC, it wasn't uploaded to the DRC portal and is now showing as a regular pending claim. The OSA and HTN are re-opens. So I think i have a pretty bulletproof packet. What thoughts do you all have? Is there anything else I should do?

My VSO let me know that my OSA appeal was denied. My original claim was a direct service connection. I read the sleep apnea field manual from Chris Attig and appealed the decision. On appeal I stated the OSA should be secondary to PTSD and sinusitis. I obtained an IMO from Dr Anaise and a DBQ with the at least as likely as not and medically necessary (CPAP) statements from my psychiatrist. My question is on appeal can you submit evidence to make it a secondary condition or does it need to be filed as secondary from the beginning? I haven't received the RAMP appeal denial letter yet. Also is there a section in the 38 CFR regarding secondary conditions with an original direct service connection claim?

Hey everybody! Long time lurker, first time poster. My question is regarding the sleep apnea language that specifies that a prescription of a breathing assistance device is "medically necessary" for a 50% rating: Assuming that a vet is already prescribed a CPAP/APAP by the VA, does the sleep apnea DBQ portion under 2B "IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A SLEEP DISORDER CONDITION?" fulfill that language requirement?

I am just wondering to what extent does the VA's Duty to Infer reach? I keep seeing it mentioned but I am not finding any particular bounding rules or interpretations, so any links or opinions would be great. Take for example a post I read this morning. OP was initially rated as 70% PTSD and was not/had not been working. Said it was in his file. Asked if VA should have inferred IU. So what has to be in their file to trigger the Duty to Infer? Is simply stating they are unemployed enough to trigger the question? is a mention in their intake memo enough? from their Primary Care doc? Psychiatrist? does a discussion with the 1-800 number trigger this duty? What if they are homeless or near to becoming homeless is that enough? Do they have to have an extensive statement saying they have not worked in two decades (or whatever) and don't think they ever will again? Would the duty to infer by itself require the VA rating decision to mention IU or send the IU form with an explanation? For example my latest rating decision for SMC K include a statement that I might have a claim for Voiding Dysfunction and tells me to file a "new" claim if I want to explore being rated for it. To my mind this is a Duty to Infer action on the part of the Rater; taking that back to the 70% PTSD example should there also have been a statement inferring possible IU and the forms needed to process such a claim? What about something like sleep apnea? I know the rules have changed on needing a statement that CPAP is "Medically necessary" but what if under the old rules a sleep study is done, a cpap issued and following that a C&P finds the veteran to be Service Connected for PTSD and has Chronic Sleep issues? Should the rater 'infer' that C&P is in order, or does the veteran have to intuitively know (yeah right) that SA is a ratable condition and then has then file a new claim? what about under the new rules? how would a new veteran know that their sleep apnea might be a ratable condition if service connected? doesn't the VA have an obligation to tell us if some condition is potentially a ratable condition or secondary to a rated condition? I cannot imagine it was the intention of Congress for Veterans to have to know things and rules they could not possibly be aware of before they file claims, particularly veterans new to the VA process. In that light it makes zero sense that legal requirements such as a Duty to Infer would/could be narrowly interpreted. Any links, discussions, BVA or CAVC results, etc would be appreciated.

I need to learn more about inferred claims and how they are decided/spotted by the va raters and acted on. The situation is I was rated 70% PTSD in 2013 around july was that C&P. In april 2013 I had a C&P for Bilateral Hearing loss and one for Sleep apnea. I knew nothing about secondary conditions, inferred claims, etc and by this time my VSO was awol dealing with pancreatic cancer (so I don't blame him). This year in July I was notified about a Review PTSD C&P, and that started me on the information hunt. I learned that ED, which was well documented in my VA med records before the first C&P, was/could be a secondary to PTSD. I also learned the Sleep Apnea was/could be a secondary to PTSD and my Sleep Study produced a CPAP and diagnosis of OSA and my Epworth Sleepiness Scale: 20/24 Since I knew nothing about secondary claims then I did not file for them then. With the PTSD Review this year I filed a claim for SMC-K for the ED. Today when Ebenefits was unaccessible I called Peggy who told me the claim was partially complete and a letter had been/was being mailed out today. The only issue left was on dizziness. This was in the A.m. Around 1 p.m. I tried ebenefits again and it was up. Under my disabilities tab it shows that I am 0% for ED Service Connected and awarded SMC-K1 with an effective date of 20 Aug 2018 the date I filed that claim I have filed an ItF on the SA claim but was waiting until this cleared. What I need to find out are the boundaries on "inferred claims". Meaning what does and does not need to be in the record for me to claim an EED back to the date of my PTSD claim. The ED was in my record before the PTSD C&P and the doc and I discussed it. He did not opine either way and the benefits award letter is completely void of any reference to it. Is it likely to be worth the trouble trying to file a claim for the EED on this? the evidence is there but no statement tying the two together back then, but I feel i should have been inferred by the rater. The SA claim is the same but a little different. The VA recently changed its requirements for granting service connection for OSA. It used to be, until this year, that being prescribed the CPAP was considered to be sufficient to read as "being medically necessary", but the new regs require that specific statement in the file. For this claim I know I have to have the diagnosis made as service connected as a secondary to PTSD so what I would like opinions on are what the value of asking to have the VA decide based on the old standard as I was unaware it was even a ratable condition. No one at the VA mentioned it. The rater on my initial Claim did not comment on it in the Award Letter. I believe this should also have been inferred. the two items are all over my records as being present months before the C&P and I am hoping that the Duty to Assist which includes a Duty to Infer will cover my claims. Any thoughts?

Facts regarding claim: Sleep Apnea secondary to insomnia Date of diagnosis: 7/18/2014 Current disabilities relevant to claim: Tinnitus – Service Connected - 6/5/2017 Insomnia – Servicee Connected - 4/13/2018 Facts regarding claim: Sleep Apnea secondary to insomnia Date of diagnosis: 7/18/2014 Current disabilities relevant to claim: Tinnitus – Service Connected - 6/5/2017 Insomnia – Servicee Connected - 4/13/2018 Status of claim: CUE submitted due to errors in claim by Rater Status of Cue: In process. Mistakes accepted as grounds for CUE Purpose of claim: Establish to VA my service connected disabilities Insomnia and tinnitus are aggravating the symptoms of my non-service connected disability sleep apnea. Sleep Apnea Symptoms: Hypersomnolence & Fatigue Service Connection Justification: Per CFE > Title 38 > Chapter I > Part 3 > Subpart A > Section 3.310: Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. Narrative: My service connected secondary insomnia and my service connected tinnitus are responsible for my sleep deprivation which is aggravating my sleep apnea symptoms: hypersomnolence and fatigue. Incident: On 27 September 2018, I went to my scheduled C&P examination expecting to answer questions about my sleep apnea symptoms (hypersomnolence and fatigue) being aggravated by the sleep deprivation I am experiencing due to my service connected tinnitus and insomnia disorder. When I got to my appointment, the C&P doctor just wanted to see my 2014 sleep study. There were no questions asked. I asked what was the reason for this C&P exam? The doctor stated he just needed dates from my sleep study. Since the VA already has this information, I was very confused as to why I was asked to attend an appointment to gather information that they already possess. I then contacted QTC who notified me of my appointment and according to the claim specialist the one question that the C&P doctor was tasked to answer was "Is the veterans sleep apnea at least likely or not proximately due to or the result of tinnitus" This question the C&P physician was tasked to answer has nothing to do with what my claim is even about. My tinnitus didn’t exist when my sleep apnea was discovered. The CUE for which was created because of a mistake made much like this one on the original claim clearly states: Because of the constant ringing in my ears that never changes in volume or goes away at any time (severe tinnitus), I am suffering chronic secondary insomnia as well as chronic migraine with tension headaches. My service connected secondary insomnia is responsible for my sleep deprivation which is aggravating my sleep apnea symptoms (hypersomnolence and fatigue). Request compensation for the aggravation of my sleep apnea symptoms (hypersomnolence and fatigue) from my service connected tinnitus and insomnia disorder. I submitted a VA Form 21-4138 and said stated: The question you tasked the C&P doctor to respond to does not at all pertain to the purpose of the claim you are evaluating. Since my sleep apnea was diagnosed in 2014, and my tinnitus was service connected 6/5/2017, how would you expect this doctor to provide a credible response to your question? My tinnitus didn’t exist in 2014. I stated: Did you not thoroughly examine the CUE (clear and un-mistakable error) and claim you are responsible re-evaluating? Are you not supposed to do this before sending someone to a C&P examination appointment for apparently nothing? Did you not check the service connection dates of my disabilities: tinnitus and insomnia along with the date of my sleep study? Doing this would have provided you vital information about my claim in that my sleep apnea was present before I was awarded my tinnitus service connection. This is a secondary service connection by aggravation claim. Please read carefully the Claim and then the CUE created because of how badly the original claim was handled. It states the circumstances leading up to my sleep deprivation I am experiencing which is causing the aggravation of my sleep apnea symptoms hypersomnolence and fatigue. I ended it with this question. How could anyone expect to get a fair claim decision if the VA representative handling their claim doesn’t bother to examine all information pertaining to the claim they are evaluating? There it is. I also put in a complaint using IRIS including everything you see on this post. I am expecting to do another CUE. My question after all of this. Is my claim valid?

Seems the VA can on occasion consider obesity merely as a "symptom"* and perhaps even the type of symptom that the VA alleges is caused by the Veteran's own willful misconduct of overeating or being inactive so it can deny the claim. However, since the American Medical Association ( AMA ) recently in June of 2013 has officially declared that "obesity is a disease", might that allow disabled veterans whose service connected condition(s) led to excessive weight gain to now find more success claiming obesity as a ratable secondary medical condition or a disease aggravated by the Veteran's service connected condition(s)? *"Obesity Service connection is not warranted for obesity. Claiming service connection for obesity amounts to claiming service connection for a symptom, rather than for an underlying disease or injury which may have caused the symptom. In this respect, obesity, in and of itself, is not a disability for which service connection may be granted. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has defined "injury" as "damage inflicted on the body by an external force." See Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003), citing Dorland's Illustrated Medical Dictionary 901 (29th Ed. 2000). Thus, obesity caused by overeating or lack of exercise is the result of the veteran's own behavior, and as such is not an "injury" as defined for VA purposes. See Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003) (defining "injury" as "damage inflicted on the body by an external force"). The Federal Circuit also defined "disease" as "any deviation from or interruption of the normal structure or function of a part, organ, or system of the body." Terry, 340 F.3d at 1384, citing Dorland's at 511. Obesity that is not due to an underlying pathology cannot be considered to be due to "disease," defined as "any deviation from or interruption of the normal structure or function of a part, organ or system of the body." Id. The body's normal storage of calories for future use represents the body working at what it is designed to do. It is well settled that symptoms alone, without a finding of an underlying disorder, cannot be service-connected. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001)." - from a BVA 2009 Decision ---and--- "Obesity or being overweight, a particularity of body type, alone, is not considered a disability for which service connection may be granted. See generally 38 C.F.R. Part 4 (VA Schedule for Rating Disabilities) (2009) (does not contemplate a separate disability rating for obesity). Rather, applicable VA regulations use the term "disability" to refer to the average impairment in earning capacity resulting from diseases or injuries encountered as a result of or incident to military service. Allen v. Brown, 7 Vet. App. 439, 448 (1995); Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); 38 C.F.R. § 4.1 (2009). The question is thus whether the current obesity is a disability-i.e. a condition causing impairment in earning capacity. In this case, there is no such evidence. The veteran has not asserted that obesity causes impairment of earning capacity; instead he asserts that his obesity has caused other disabilities to manifest. There is also no other evidence that the claimed obesity is a disability. Inasmuch as the Veteran does not have a disability manifested by obesity and obesity is not a disease or disability for which service connection may be granted, the Board concludes that obesity was not incurred in or aggravated by service and may not be presumed to have been so incurred. This claim is not in relative equipoise; therefore, the Veteran may not be afforded the benefit of the doubt in the resolution thereof. Rather, as a preponderance of the evidence is against the claim, it must be denied. 38 U.S.C.A. § 5107(b) (West 2002)" - from a 2010 BVA Decision But didn't the VA as early as 2006 already characterize obesity as a disease? "Obesity is a complex and chronic disease that develops from an interaction between the individual’s genotype and the environment." - http://www.healthquality.va.gov/obesity/obe06_final1.pdf "The AMA's decision essentially makes diagnosis and treatment of obesity a physician's professional obligation." - Los Angeles Times http://www.today.com/health/obesity-disease-doctors-group-says-6C10371394

Hello Hadit.com Members, I am new to the site, but I have reviewed a lot of information throughout the different forums and I must say the collaborated efforts to assist an in need fellow veteran is refreshing. Hopefully I am not too much of a burden with my situation and hopefully I can benefit from your guidance because right now I am at a loss on how to approach my claims. I am currently service-connected for TMJ - 20%

So to make a long story short, I was active duty since 1994 and medically discharged in 2005. Since around 99/2000 I have suffered from what I now know as sleep apnea. I was never tested for it during service, but I had no idea what the heck it even was. Only knew I was being woken up by my wife, and when in the field or deployment soldiers, because I would snore loud and then stop breathing. I placed an initial claim for this in 2010 after I had a surgery at the VA, and I was placed in the ICU due to low oxygen levels and having sleep apnea during surgery. 04/2010, I did the first claim on my own and it was quickly denied. 10/2010, I re-opened the claim with 3 buddy letters of soldiers who witnessed me in the same close sleeping questers during deployment, stop breathing. Had a C&P exam, with a doc who spent all of 3 minutes asking me directing questions. It too, was denied. 04/2012, I re-opended it again after I had my actual VA doc write me a nexus letter claiming it was "more likely than not" related to service and a new buddy letter from a service member who shared quarter with me in various units, and from my wife. It too, was denied. 02/13, I submitted the NOD, and had a DRO review, it too was denied. 02/15, I submitted the appeal, with the help of Military Order of the Purple heart. It was received 03/2015 and and it was been sitting since 09/2015 at "Awaiting place on docket" Anybody have this type of claim? Trying to use secondary evidence and Nexus letters because you have no service record of it? The advice I have been given depends on who I have asked. I have been told, I should have been awarded due to mixed views and having the benefit of the doubt. I have been told I have no chance without a record of it in service. I have been told it is just the process I have to go through, the VA denies denies denies and dwindles down the hopefuls to very few who will take it all the way through appeals. I have been told both do do a congressional investigation because it worked, and to not do a congressional because I will only provoke a quick "no" answer. I am hoping someone who has been in my shoes can tell me what they went through. I have no idea how long I will be in this appeal process, but I am now going on six years fighting this thing, although for the VA they only go back to the last time you re-opened so for them 4 years.

Finally got my Sleep Apnea DBQ and Nexus Letter back from my doctor. E-Benefits is showing Disabilities Claimed: sleep apnea to include due to aggravtion by ptsd (New) I had my military treatment records, C&P Report for PTSD, VA Claims File for the doctor's review, but he said that he wasn't comfortable stating that he reviewed these documents since it would take him several days. Just wanted to see what everyone's thoughts are on my DBQ & Nexus letter that doesn't state that he reviewed my VA documents or military treatment records. Thanks! OEF 21B Sanitized Sleep Apnea DBP and Nexus Letter_27 JUL 15_Redacted.pdf

Just saw on E-Benefits that my Sleep Apnea claim as secondary to PTSD was granted at 50%. For the Sleep Apnea: - No history of sleep issues while on active duty or in STRs - VA Psych requested sleep study, Sleep Study completed by VA-Outsoursed Hospital, Diag. w/mod. Sleep Apnea and issued a VA CPAP in May 2013. - My private Sleep/Pulminary Doc completed Sleep Apnea DBQ & wrote nexus letter stating "Based on my evaluation of the veteran, it is my opinion that it is at least as likely as not that Mr OEF21B's diagnosed OSA is aggravated by his service connected PTSD. I also feel that it is at least as likely as not that Mr OEF21B's PTSD is aggravated by his OSA." (17 JUL 15) Filed Sleep Apnea claim 28 JUL 15 - Sleep Apnea C&P in AUG 15 with the Veterans Evaluation Services (VES). Brought copy of DBQ and Nexus Letter as well as some of the articles linking PTSD & SA. I thought the C&P went well and the Dr. said that she would add the articles as well as my DBQ & Nexus letter to her final report. IMHO, I believe that my private doc's completion of a DBQ as well as his Nexus letter was key in meeting the requirement for service connection secondary to PTSD. I also believe that providing these along with the articles listed here in various places, and providing all of this to the C&P examiner helped. Semper Fi

Hello all, I separated in 2007 and was awarded 80% for a number of things (listed below) after awards I have never made another claim. Since I got out I've used the VA for some care for my eyes and CPAP gear but not for everything as I have private insurance. Last month on Dec 21st I had a heart attack at 37 years old (turned 37 2 weeks before on Dec 11th) with 1 each 100% blockage requiring a stent. I was not on cholesterol or BP meds and I receive no disability for any cardio related issue. I had an electrocardiogram and my heart looks great with 100% function and my non VA cardiologist said I have to take plavix for a year and likely statins and BP meds for life but other than that no restrictions and no other damage. I read that OSA causes issues including heart attack but I have had high normal cholesterol since I was active duty (ldl 150ish, tri - 100+, hdl 40s, total 210+) and normal BP always. My questions are: 1 - Can I tie the MI event to OSA? And if so can it cause the MI even if my BP and Cholesterol are not really considered high? 2 - If I have 100% function and no damage is it worth the effort? disabilities Disability Rating left knee strain 0% left ankle strain status post talar break 10% right ankle strain 10% multi-level degenerative disc disease, thoracolumbar spine (claimed as lumbar and thoracic back conditions) 10% bilateral keratoconus 30% tinea versicolor 10% allergic rhinitis (also claimed as sinusitis), status post septo-rhinoplasty 10% tinnitus 10% central sleep apnea 50%

Has anyone had any luck with claiming Sleep Apnea as secondary to Hypertension and/or Arteriosclerotic Heart Disease ? My husband has service connection for both hypertension and heart disease and now a current diagnosis and medical equipment for sleep apnea. I've read where VA has approved hypertension secondary to sleep apnea and heart disease secondary to sleep apnea, but not the other way around. If anyone has an archived VA citation in this regard, or personal experience, would greatly appreciate hearing about it. Thanks all.