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Whirly Bird

Received C&p Notes For Sleep Disorder Secondary To Ptsd/and Gulf War Presumptives(Wags?)

Question

All, I have a claim in for service connection of Sleep Disorder secondary to PTSD/Gulf War Presumptives. I just received the following C&P medical opinion and was hoping that some of you in the know might be able to give me some WAGS? Will this most likely be rated as Sleep Apnea with use of CPAP? 50% Rating?

thanks in advance

Sleep Apnea
Disability Benefits Questionnaire

Name of patient/Veteran: XXX

Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

VA electronic medical records (CPRS) reviewed.
VBMS reviewed.

If no, check all records reviewed:

[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:

1. Diagnosis
------------
Does the Veteran have or has he/she ever had sleep apnea?
[X] Yes [ ] No

[X] Other sleep disorder, specify: other and unspecified sleep apnea
ICD code: 780.57 Date of diagnosis: February 15,
2005

2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's sleep
disorder condition (brief summary):
The veteran served in the Gulf War from August 1990 through April/May
1991 he is claiming "unspecified sleep disorder", treated as sleep
apnea
with CPAP for the past 9 years. Symptoms at the time of testing
included headaches, dizziness, confusion, unrestful sleep, and
witnessed
apneic episodes during which the veteran would awaken, gasping for air.
He has been using a CPAP machine for the past 9 years with moderate
relief of symptoms. He is claiming that Gulf War veterans are awarded
service connection for "undiagnosed sleep disorders" as a presumptive
Gulf War condition.
He is also claiming that the condition is secondary to, but separate
from, PTSD.

b. Is continuous medication required for control of a sleep disorder
condition?
[X] Yes [ ] No

If yes, list only those medications required for the Veteran's sleep
disorder condition:
Hydroxyzine pamoate, prazosin

c. Does the Veteran require the use of a breathing assistance device such as
continuous positive airway pressure (CPAP) machine?
[X] Yes [ ] No

3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms attributable
to sleep apnea?
[X] Yes [ ] No

If yes, check all that apply:
[X] Persistent daytime hypersomnolence
[X] Other, describe: Difficulty with concentration, fatigue.

4. Other pertinent physical findings, complications, conditions, signs
and/or
symptoms

-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?
[ ] Yes [X] No

5. Diagnostic testing
---------------------
a. Has a sleep study been performed?
[X] Yes [ ] No

If yes, does the Veteran have documented sleep disorder breathing?
[X] Yes [ ] No

Date of sleep study: February 15, 2005

Facility where sleep study performed, if known: John Cochran
pulmonary sleep lab, John Cochran VA Medical Center, St. Louis,
Missouri.

Results:
Unspecified sleep apnea. Prescribed CPAP. Veteran has been using
CPAP for the past 9 years

b. Are there any other significant diagnostic test findings and/or results?
[ ] Yes [X] No


6. Functional impact
--------------------
Does the Veteran's sleep apnea impact his or her ability to work?
[X] Yes [ ] No

If yes, describe impact of the Veteran's sleep apnea, providing one or
more examples:
The veteran works for XXX. Because of PTSD
issues the veteran works from home via computer. The veteran states
that he has difficulty concentrating and fall asleep easily when
working.

7. Remarks, if any:
-------------------
Please see medical opinion worksheet.



****************************************************************************


Medical Opinion
Disability Benefits Questionnaire

Name of patient/Veteran: XXX

Indicate method used to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
a. Was the Veteran's VA claims file reviewed? Yes

If yes, list any reco
rds that were reviewed but were not included in the
Veteran's VA claims file:
VA electronic medical records (CPRS) reviewed.
VBMS reviewed.

MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Is the veteran's sleep condition at least
as
likely as not related to his PTSD or the results of military service?

b. Indicate type of exam for which opinion has been requested: DBQ Sleep
Apnea

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event
or
illness.

c. Rationale: It is examiner's opinion that the veteran's "sleep apnea" is
an
undiagnosed illness secondary to service in Southwest Asia. According to
the
Gulf War General Medical Examination DBQ, an undiagnosed illness is
established when findings are present that cannot be attributed to a known,
clearly defined diagnosis after all likely possibilities for such
abnormalities have been ruled out. The veteran's sleep study at John
Cochran
VA Medical Center pulmonary lab did not conclusively diagnose obstructive
sleep apnea but the veteran has been treated with success using CPAP machine
as if he were diagnosed with obstructive sleep apnea. His diagnosis is
listed as "other and unspecified sleep apnea" in his VA problem list.

The veteran further claims that his sleep condition is secondary to, but
separate from, PTSD. Supporting this contention are studies done by Brooke
Army Hospital and Walter Reed Army Hospital. In the Brooke Army Hospital
report, entitled Sleep Disordered Breathing in Combat Veterans with PTSD,
researchers concluded that "data show that more than 70% of those
active-duty
members who carry a diagnosis of PTSD are at risk for the diagnosis of
obstructive sleep apnea".
In the Walter Reed Hospital report, entitled Prevalence of Sleep Disorders
among Soldiers with Combat Related Posttraumatic Stress Disorder,
researchers
concluded that "sleep complaints were almost universal among soldiers with
PTSD. The majority were diagnosed with insomnia and/or obstructive sleep
apnea".

In a BVA decision involving the Hartford, Connecticut VA regional office
(Docket#10-25 465) entitlement to service connection for obstructive sleep
apnea as secondary to PTSD was granted with 'Reasons and Bases for Findings
and Conclusions' based upon the studies cited above.

Therefore, it is at least as likely as not that the veteran's sleep
condition
listed as "Other and Unspecified Sleep Apnea ICD-9 Code 780.57" is due to
were the result of military service.

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After reading your post, I'm pretty sure you are correct and you will receive 50% for OSA (Since use of CPAP) secondary to PTSD.

Definitley great information. I have my OSA on appeal since they diagnosed me with sleep apnea and va gave me a cpap, but it isnt service connected currently. I have PTSD 70% and 90% combined, was medically retired (PDRL) from USMC for PTSD & bilateral shoulder issues. I gained 125-150lbs, due to my ptsd depression, which i think has attributed to my sleep apnea. NIce intel, on the cases. I had a sleep study as well by the VA. never had IMO or anything, did you?

sorry to hijack your post.

congrats and semper fidelis

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You will get the 50% bud. Good luck and keep us posted

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WOW - That opinion surely provides a diagnosis and nexus as

secondary to your PTSD, so as long as the PTSD is SC'd, this looks good to go.

jmho

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Thanks for the input everybody. I had the C&P for PTSD on the same day. I shouldn't have any problem getting it service connected though, as I have combat awards, diagnosis, and nexus from the VA docs that the PTSD is related to combat. (still waiting on the C&P notes for that exam though).

As far as the sleep disorder goes, I submitted several studies that link sleep disorders as a secondary condition to PTSD, along with a copy of a BVA decision that granted service connection of sleep apnea secondary to PTSD based on those same studies. I also asked the VA to consider the sleep disorder as a presumptive per CFR 3.317 Gulf War Vet regs. since it is technically not diagnosed as "Sleep Apnea". My docs aggreed with me, and looks like the C&P doc did too.

I don't want to get to excited yet, but it's lookin pretty good...........Keep yer fingers crossed for me.

Edited by Whirly Bird

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If any of ya'll are interested, I've attached the studies and BVA decision below that I used as evidence in support of this claim. Maybe these will help somebody else out there.

Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort.pdf

OSA Secondary to PTSD 1.pdf

OSA Secondary to PTSD 2.pdf

BVA Decision.pdf

Edited by Whirly Bird
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