Criteria the VA uses to assign a 50% rating to VA Sleep Apnea Claims has just changed

[Tbird]

The Veterans Law Blog just got word today that the criteria the VA uses to assign a 50% rating to VA Sleep Apnea Claims has just changed, effective April 18, 2016. http://www.veteranslawblog.org/va-sleep-apnea-ratings-rules-changing/

[VetlawUS]

2 hours ago, brokensoldier244th said:

All it says that that you have to have evidence that a CPAP or breathing assistive device is required. Nothing about a specific  "letter from a doctor stating medical necessity...." as VLBlog says. If you have a prescribed CPAP then you already have this, anyway. If you have a CPAP with no medical backing or prescription, but just because you 'think' you need one, then no, you should not be getting a rating for it. The other part says they can't go and change your rating for not using one if you have one prescribed. 

 

This change is common sense, IMO. 

I would like to think that the prescription is all that is required, but that would render the VA's distinction between "use" and "necessity" pointless.  

And keep in mind, the 50% rating has ALWAYS said "Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine".  The VA has been, until now, accepting the Rx as the proof of necessity.  No longer - they want something more. 

The only way to get a CPAP, to my knowledge, without a prescription, is to pay cash for the machine.  And in 10 years of doing these claims, I have not once seen a Veteran pay cash to have a machine.  There is almost always a prescription from the pulmonologist, neurologist, or MD that wanted the Vet to use it.

I don't see the change as common sense, either, as we all know that VA doctors are very reluctant to write statements in support of Veteran benefits claims.  

[VetlawUS]

1 hour ago, brokensoldier244th said:

No one, including me, said that just having a medical need for a CPAP ensures a rating. The blog implies that vets that already have CPAPs will now need to have this letter of medical necessity to combat a rating reduction. You still have to have an in service connection for SA- this change to M21 doesn't change any of that. Hence my confusion due to the blogger seeming to say that this change is a huge deal. If your doctor prescribes your machine you already have the 'necessity' part covered. The SC consideration is still on you and your doctor to establish. 

 

Just having a CPAP is not a 50% rating, nor should it have ever been. 

You are correct that this change affects teh rating only...if you cannot service connect Sleep Apnea, this change is irrelevant to you. 

Now, as I mentioned above, this change is huge, because the VA is making a subtle distinction between it's past approach to allowing the Rx from the doctor for a CPAP to suffice for medical necessity proof.  No more - be careful not to read the words on paper in isolation from the VA's prior practice and prior rules. 

If I'm wrong, and the VA continues to accept the prescription as the sole proof of medical necessity for a B.A.D., I will gladly eat crow.

But in 10 years of predicting how the VA is trying to f**k the Veteran, I've never once had to eat crow.  

[VetlawUS]

1 hour ago, Buck52 said:

yes the link I Put up above is out dated (2013) my point was the VA was preparing for this new change Chirs Attig Mention to Ms T...

So a bunch of us are trying to find the new S.A Changes...I been looking in the M-21 Manual  and not yet found the change?

.............Buck

Here it is in the online knowledge database.  I will post the PDF on my site when the new M21-1MR update is released in PDF. 

Go to: 

III.iv.4.D.1.o. Evaluating SleepApnea

http://www.knowva.ebenefits.va.gov/system/templates/selfservice/va_ss/#!portal/554400000001018/article/554400000014197/M21-1-Part-III-Subpart-iv-Chapter-4-Section-D-Respiratory-Conditions?fromQuery=sleep apnea

[Tbird]

chris thanks for jumping in.

[VetlawUS]

On 4/18/2016 at 1:11 PM, brokensoldier244th said:

 Im sure there are doctors that will issue that stuff since insurance pays for it that don't document the rationale why they prescribed one- and even if they prescribed it that should take care of the letter requirements anyway. Not sure what the doom and gloom is to the first part of this change. I also see that Chris does not cite the relevant portion of the criteria, either. 

 

As to the cite, see the link below....I will post the PDF on my site when the VA releases the PDF M21-1MR update.

Is your Sleep Apnea service connected, brokensoldier, or do you have actual experience with these claims?   

[brokensoldier244th]

Point taken, Chris, but the regs don't say that a letter is necessary, therefore, experience or not- I feel its a bit disingenuous for you to say so on a blog that is connected to multiple other veteran resources. As a lawyer, you know the importance of proper citation and context.