Sleep Apnea Claim

[EODCMC]

Hi, I am a 30 year retired vet. I retired 13 years ago. I as recently diagnosed with "very severe" obstructive sleep apnea. The machine they gave me is preset on the highest output flow. My episode exceed 35 times an hour with some lasting more than 30 seconds. 

I was diagnosed with sleep apnea a couple of years prior to retirement and the study and diagnosis is documented in my record. In fact, they wanted to operate on my uvula. There lies the rub. The operation could have ended my career so I didn't persue. Additionally, while on active duty I developed severe chronic sinusitis and allergic rhinitis and this also is documented in my service health record. I have been living with this and chalking it down to getting old.

Fast forward...I recently got a machine that they say I have to wear for the remainder of my life. I just learned that Tricare Prime does not pay for it all. So, I researched online and submitted a claim the E-benefits and it has been received and was under review until today when they changed this to "gathering of evidence" Development Letter Sent.

Does anyone know what this means? What do I have to look forward to concerning the process. I watch the news. It doesn't look good, right?

thanks in advance.

[EODCMC]

Yes, she specifically referenced the 2002 Navy Medical Center Sleep Study and went on to say that  " it showed OSA in the mild degree. Therefore, a continuing worsening symptoms of his sleep apnea that was already noted since 2002. This is in support of claim of his medical condition that has exacerbated thru time". Yes, It could have been worded differently and even better, yet I think it's as good as the canned statement that it's more likely than not a result of SC blah blah blah. It shows that it was DX'd on active duty and has worsened. But, you have seen more of these than I.

[EODCMC]

So, I had my C&P exam. Buck, you were right. I think he was QTC. He actually told me the OSA was a "slam dunk". The Sinusitus, not so much. He did say; however, what I have is allergic rhinitis and it's very well documented in my service record and I should apply for that. I'm not sure how I can see the results of my C&P. Ideas anyone?

[Buck52]

Beings it was a QTC  C&P Exam  you will need to wait approx 2 weeks,   then go to the VBA ( Veterans Benefits Administration) office...Request a copy of this exam.

Usually at your VAMC.

The %maybe 50% for OSA unless the examiner mention chronic to severe  then a higher rating!

 When you can get that report and see what the examiner mention as for as the OSA Symptoms  then look up the criteria for the correct rating.  found here on Hadit.

be sure and recheck your EED Too!

 

Edited August 31, 2016 by Buck52

[EODCMC]

Thanks Buck...yes, will do.

[EODCMC]

Amazingly, my results were posted on myhealthvet this morning. Severe OSA was a slam dunk. The Dr. used those words. The Sinusitis, not so much. I'm trying to decide if I will appeal. I will post redacted copies in an hour or so. I could use some sage advice.

Edited September 2, 2016 by EODCMC
Misspelling

[Gastone]

Buck, the SA Rating would have to include (1) of the ( "OR" DXs ) listed for the SA 100% Rating, otherwise Mild to Extreme SA requiring Cpap or Bipap, with or without supplemental 02, is capped at a 50% rating.

There is a possibility, if the Vet has a SA DX requiring the use of supplemental 02 in conjunction with his Cpap or Bipap, due to P02 dropping below 90%, a case for evidence of Chronic Respiratory Failure should be addressed. That would cover (1) of the "ORs" required for the SA 100% Rating or Increase.

While working on my own 2014 SA Increase, I reviewed numerous BVA Awards that indicated a SC SA DX requiring  Nocturnal use of Supplemental Oxygen, met the "Chronic Respiratory Failure" Evidence for a SA SC increase.

The VA SA 05/2015 C & P Dr, didn't agree with my position, told me my 50% was it, couldn't get anything higher, said I was "wasting both our time." The VA (Reg Axx) Rater agreed with him, Denied my Increase 07/15.

However, a SR Rater doing a Quality Control Review in 11/15, reversed 07 Denial because of my 100% SA "ORs". I should track down the VMC Dr that did the SA C & P, show him the Award. "Wasted our Time," My ASS. SA 100% Scheduler (formerly IU T & P No future exams) and SMC S (1) with 20 months of Retro, certainly wasn't a waste of my time.

Semper Fi