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Appeal To Split Combined Vagal Nerve Reflex And Benign Paroxismal Positional Vertigo

Question

Hope I am am posting to the right place. I received 0% on Sensitive vagal parasympathetic nerve reflex and benign paroxysmal position vertigo. These two disabilities (claimed as pre syncope syndrome and vertigo) are evaluated together because the share etiology and symptoms.

I don't believe that these two disabilities should be lumped together. I don't believe that there should be 0% on either of these two disabilities.

I started my appeal with a rough draft and wonder if anyone could take a look at what I'm saying and see if my research and reasoning are on the right track. The rough draft follows:

Any feedback is appreciated.

Appeal to separate the benign paroxysmal position vertigo from the Sensitive Vagal parasympathetic nerve reflex.

Appeal: My appeal is to separate the benign


paroxysmal positional vertigo and the sensitive vagal parasympathetic nerve
reflex into two separate claims. The
first being rated as 6420 at 30% and the second being rated as 8210 at 30%. The
following is my argument and supporting medical history for the two ratings:


I experience dizziness frequently in several different


ways: The primary experience is the
momentary feeling of falling or tumbling that lasts for several seconds. It causes me to stumble when walking, or seek
firmer footing when standing and use my hands to stabilize when seated. The feeling comes when least expected and
happens on a frequent weekly basis.

I also experience is a sensation of having my environment

continue to move when I stop or change directions. For example I can be standing still and turn
myself to see or respond to someone calling out to me and the turning sensation
will continue after my body stops. This also happens when I am walking in a straight line and turn a corner. I will feel as if my body is still moving in the direction that I was going before turning the corner. (I am in the process of going through my 900 pages of medical records to show where I have complained to doctor and neurologist about this)


In _(Find date oftreatment)______ I experienced an incapacitating case of benign paroxysmal

positional vertigo where I was unable to move between laying down and sitting
up without incapacitating dizziness and nausea.
I went to the flight surgeon that was very familiar with this condition
and he treated me using a head movement method called “the Eply maneuver” where
the head is moved along various rotational planes for approximately 30
seconds. The Eply maneuver is used to help
usher out tiny crystals of calcium carbonate, which are a normal part of the
inner ear’s anatomy, that have detached from the otolithic membrane and settled
in one of the semi-circular canals. The
procedure worked, I was able to function normally after the procedure. This fact lends itself to a certain diagnosis
of BPPV.


Through my treatment of BPPV and discussion with the flight


surgeon, his estimation was that there are many different causes for BPPV and
unless the symptoms persist and are incapacitating, there is no reason for a
grounding status and there is no good explanation for why some people get it
and some don’t. The most common cause of
BPPV for persons under 50 is concussive force to the head. The flight surgeon explained that exposure to
explosions or noises so loud that one can feel them in their chest or head can
lead to these calcium carbonate crystals becoming weakened and dislodge over
time.


It is important to note that no two episodes of BPPV are


expected to be the same. The size of the
calcium crystal, the position of the crystal as gravity moves it within the
semi circular canal and the magnitude of the nerve receptor response will all
play a part in the intermittent pattern of symptoms. One common theme of BPPV is the symptoms
present themselves in relation to movement against gravity.


The rating for BPPV

should come under 6204
Peripheral vestibular disorders: I believe I should be rated at 30% for this
service connected dysfunction because of the occasional staggering, the need to
reposition when standing still and needing to find something to hold on to when
seated and having occasional dizziness.


Peripheral vestibular disorders
6204
Dizziness and occasional staggering......................................................................... 30
Occasional dizziness................................................................................................. 10
Note: Objective findings supporting the diagnosis of


vestibular disequilibrium are required before a compensable evaluation can be
assigned under this code. Hearing impairment or suppuration shall be separately
rated and combined.


The essential part of my argument to split the BPPV rating

apart from the Sensitive Vagal Parasympathetic nerve reflex is that the BPPV
was identified by an incapacitating episode of dizziness and treated
successfully using the Eply maneuver.


The second part of my argument is centered around a


well-documented conclusion that the vagal Parasympathetic nerve reflex (VPNR)
is caused by position of the neck specifically, it affects the 10th
cranial nerve as it travels down the right side of my neck and specifically
where the Vagal node is located where one would check for a pulse on the carotid
artery.


Background: Post


surgical fusion of my neck and subsequent physical therapy dated and documented
_date_ brought about a correlation
between executing the stretching exercises assigned and a feeling of fainting,
or the dizzying panic that comes with a rapidly lowering heart rate and blood
pressure. I had been assigned a stretch
to reach up with my left hand and pull my head directly to the side. This stretch caused the right side of my neck
to stretch out and subsequently allowed me to draw an undeniable relationship
between the position of my neck and the feeling of being ready to loose consciousness. Throughout the period from cervical surgery
to present day I have suffered from episodes that felt as if I was going to
faint. The symptoms could be grouped
into simple dizziness, but they are very different. The more frequent these episodes became the
more I was able to narrow down the position of my neck. The example I gave to the doctor, which
allowed me to see a cardiologist is one where I was driving down the road and
talking on my cell phone. I had the
cruise control on and was lazily laying on my right side, right elbow on the
center map case with my cell phone in my hand.
This was causing my neck to be flexed in such a way that the vagas nerve
was affected and it caused the vagal response.
I felt dizzy, flushed; panicked and thought I may loose consciousness. I immediately hung the phone up, sat up
straight and focused on driving. The
symptoms left me as quick as they came and I felt normal. During the same drive I resumed my phone
call. For the second phone call, I
placed my left elbow on the driver’s side window to hold my phone in the left
hand. I leaned my head to the left in
such a way that it stretched the right side of my neck and I quickly had the
same symptoms as before and I learned that this panicky dizziness with
impending feelings of loosing consciousness were brought on by the position of
my neck and held stationary in such a way that the vagas node on the right side
of my neck was affected. The range of
motion is quite small that brings about the vagas response. The physical therapy provided where I was
actively pulling my head to the left and inducing the response and the more
slight tilt of my head directly to the left allowed my cardiologist to draw the
conclusion that the Sensitive Vagal parasympathetic nerve reflex was caused by
some type of dysfunction on the right side of my neck where the Vagal node is
located.


The rating for sensitive vagal parasympathetic nerve reflex should come under 8210 Peripheral vestibular disorders: I

believe I should be rated at 30% for this service connected dysfunction because
of the extent of sensory and motor loss to my blood pressure, heart and
respiratory system. There is frequent
dysfunction, which can lend itself to distracting and dangerous situations.

Tenth (pneumogastric, vagus) cranial nerve
8210

Paralysis of:

Complete 50
Incomplete, severe..................................................................................................30
Incomplete, moderate..............................................................................................10
Note: Dependent upon extent of sensory and motor loss to organs of voice,

respiration, pharynx, stomach and heart.









































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"These two disabilities (claimed as pre syncope syndrome and vertigo)
are evaluated together because the share etiology and symptoms.


I don't believe that these two disabilities should be lumped together."

I dont either because the diagnostic codes are so different.

You sure did a lot of medical homework here and that is often what it takes to get a higher rating.

I learned ,as a hardcore claimant, that VA cant handle too much at a time . What I mean is , if this can be pealed down to just telling them this is a Notice of Disagreement with the rating they gave you and then tell them why those ratings are wrong and list as evidence, any medical evidence (dates and even copies of it will help ) that warrants the higher rating ,in the NOD, it might help a lot.

Do you feel the VA considers the Eply maneuver as a cure for BPPV?

Is there any medical reason to assume that? This is a facinating maneuver many people are unaware of. I hope the VA understands it but I dont know how VA views it.

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Tenth (pneumogastric, vagus) cranial
nerve

8210


Paralysis of:


Complete
50
Incomplete, severe..................................................................................................30
Incomplete, moderate..............................................................................................10
Note: Dependent
upon extent of sensory and motor loss to organs of voice,


respiration, pharynx, stomach and heart.


Peripheral vestibular
disorders

6204
Dizziness and
occasional
staggering.........................................................................
30
Occasional dizziness.................................................................................................
10
Note: Objective findings supporting the diagnosis of




This BVA case expands that definition a
little:


Under Diagnostic Code (DC) 8210, a 10 percent rating is 
warranted when there is evidence of moderate incomplete 
paralysis of the tenth cranial nerve.  The severity of 
impairment is dependent upon the extent of sensory and motor 
loss to organs of voice, respiration, pharynx, stomach and 
heart.  In order to receive a rating of 30 percent under DC 
8210, the evidence must show that manifestations of the 10th 
cranial nerve disability more closely approximate severe 
incomplete paralysis of the tenth cranial nerve.  In order to 
receive a rating of 50 percent under DC 8210, the evidence 
must show that complete paralysis of the 10th cranial nerve.


http://www.va.gov/vetapp08/Files5/0843253.txt




Also, VA is using analogous ratings I
believe for the DC 6204 disability.




This BVA case popped up but I am having
internet problems due to weather and cant read the decision yet.
(wind hits my sattelite dish)






www.va.gov/vetapp09/files2/0915598.txt




That case and by searching at the BVA
web site via www.va.gov/ then under
the site index, using your exact diagnoses, you might find similar
claims that could help shape your NOD appeal.




When the BVA makes a legal statement
,such as regarding an analogous rating, and DC, I feel any claimant
should refer the VA to that statement and decision,if it will help
their claim.




BVA decisions cannot be used to support
claims for a similar medical disability.




However they can be referenced as to
any legal statement in them.




I used a very old BVA decision I
received ,maybe in 1999, to support refund of my FTCA offset when I
proved my husband died due to SC AO.There is no similar case on that
at the BVA so I only had alink and excerpt from my previous BVA
case. Words to affect that,'if the widow succeeds on a direct SC
death basis, the FTCA offset to her DIC will be refunded to her.'




It was a legal statement , that I also
supported with the actual regulations ,and the VA did refund my
offset in 2010.



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Thank You Berta,

so it sounds like I'm on the right track with an appeal? I will pair down the facts and site specific Dr. visits to support the claim in a chronological order.

I don't know if the VA recognizes the Eply maneuver to 'cure' BPV, but it is a medically accepted practice to move the piece of carbon through the eustachian tubes.

Should my appeal be worded to "split" those two items, or two appeals to recognize each item on its own merit, with accompanying documentation?

VR

Frank

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I would file the NOD on both disabilities as they appear to be in the same decision you received, yet 'split' as you said your argument on each rating.

We had a post here recently on analogous ratings and maybe that will help you.

My definition of analogous is .'.we (VA) dont know what DC code to give this disability so let's throw one out there to see if it sticks'........That is just my opinion...and if the VA gets if wrong, the entire thing could change.

If you are not employed I sure think you should apply for TDIU as I think VA can handle TDIU claims better than regular claims for higher ratings.

Has any doctor suggested these disabilities (as well as the overall 70% disabilities have hindered your ability to attain substantial employment?

WOW USMC AND USAF ! Thank you for your Service!!!!!!!

Both my deceased husbands had 2 HD service periods. My daughter, however, served USAF for 7 years and wanted to work for DOD and wear high heels and feminine clothes for a change . She was in BDUs and combat boots throughout most of her service.

She loves her job at DOD.

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could someone look over part one of two for the NOD to split the two disabilities. I went back and simplified the argument, found supporting documentation (which I'll leave off for privacy). Hopefully someone will tell me I'm on the right track and I'll finish up the Vagal response argument in a few days.

Should I send them in separate correspondence?

Notice of disagreement with service connection for sensitive vagal parsympathetic nerve


reflex and benign paroxysmal position vertigo. These two disabilities (claimed as presyncope syndrome and vertigo)
are evaluated together because they share the same etiology and symptoms. They do not share the same etiology or symptoms.

Appeal to separate the benign paroxysmal position vertigo from the Sensitive Vagal parasympathetic

nerve reflex. A doctor who is feeling rushed during the appointment, or otherwise is at a lack of descriptive terms may describe the overall event as dizziness in order to simply the paperwork. I have documented instances of a vestibular disorder leading to vertigo (dizziness). Additionally, I have documented instances where there was a parasympathetic vagal nerve reflex, which was causing presyncopetic episodes and those were loosely classified as dizziness until a cardiologist made the final determination and classified those episodes as a vagal response.

Appeal:

My appeal is to separate the benign paroxysmal positional vertigo and
the sensitive vagal parasympathetic nerve reflex into two separate claims. The first being rated as 6420 (peripheral vestibular disorders) and the second being rated as 8210 (Tenth (pneumogastric, vagus) cranial nerve)


The following is my argument and supporting medical history for the Vestibular disorder:
Attachment (1)
22 January 2010, I reported the similar vertigo sensations along with stumbling over my own feet.
Attachment (2)

On November 23rd, 2009 I experienced an incapacitating case of benign paroxysmal positional vertigo where I was unable

to move between laying down and sitting up without incapacitating dizziness and nausea. I went to the flight surgeon
that was very familiar with this condition and he treated me using a head
movement method called “the Eply maneuver” where the head is moved along
various rotational planes for approximately 30 seconds. The Eply maneuver is used to help usher out
tiny crystals of calcium carbonate, which are a normal part of the inner ear’s
anatomy, that have detached from the otolithic membrane and settled in one of
the semi-circular canals. The procedure
worked, I was able to function normally after the procedure. This fact lends itself to a certain diagnosis
of BPPV.

Attachment (3)

Notes used for initial consult with Nevada Spine Clinic on

November 20, 2009. I write out notes to
avoid letting the consult degenerate into a complaining session and to pass
useful information to the doctor..

Attachment (4)
A mental health visit for which details feeling dizzy within


the last month, this for was filled out June 13, 2007, prior to any surgery on
my neck.


I have experienced frequent feelings of ‘dizziness’ as it is


related to vertigo in the past. It is
important to note that I did not mention vertigo episodes each time they
happened because of the impracticality of bringing up spurious subjects while
at a doctor’s appointment for other reasons.
I was aware of BPPV through my training as an aviator, we were made
familiar with inner ear and vestibular problems. Through my treatment of BPPV and discussion
with the flight surgeon, his estimation was that there are many different
causes for BPPV and unless the symptoms persist and are incapacitating, there
is no reason for a grounding status and there is no good explanation for why
some people get it and some don’t.


The flight surgeon explained that exposure to explosions or noises so loud that one can feel them in their chest or head, or flying a high vibration aircraft such as a helicopter. I have documented history of exposure to these activities, which can lead to these calcium carbonate crystals becoming weakened and dislodge over time.

It is important to note that no two episodes of BPPV are


expected to be the same. The size of the
calcium crystal, the position of the crystal as gravity moves it within the
semi circular canal and the magnitude of the nerve receptor response will all
play a part in the intermittent pattern of symptoms. One common theme of BPPV is the symptoms
present themselves in relation to movement against gravity.


The rating for BPPV should come under 6204

Peripheral vestibular disorders: I believe I should be rated at 30% for this
service connected dysfunction because of the occasional staggering, the need to
reposition when standing still and needing to find something to hold on to when
seated and having occasional dizziness.

Peripheral vestibular disorders
6204
Dizziness and occasional staggering......................................................................... 30
Occasional dizziness................................................................................................. 10
Note: Objective findings supporting the diagnosis of


vestibular disequilibrium are required before a compensable evaluation can be
assigned under this code. Hearing impairment or suppuration shall be separately
rated and combined.

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