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]

Gastone, my sleep report indicates that I spent more the 20% of my 8 hour study with P02 below 90%... As low as 81%. Does this indicate that I should be considered for 02? That would really be a good nights sleep.

[Gastone]

My lay opinion is definitely yes. The non VA Sleep Specialist, DX'd my need for Supplemental 02 within a week of my final night Sleep Study.

Have you discussed the P02 result with your SA Specialist? A DX requiring the Supplemental 02 while on Cpap/Bipap would support a future request for a 50% SA increase to 100% Scheduler, due to meeting (1) of the SA 100% "ORs" (DX of Chronic Respiratory Failure).

Semper Fi

[EODCMC]

Thanks...does the 02 help with the symptoms?

[Gastone]

Absolutely and you'll notice the effect's of the 02 supplementation, after the 1st night.

You understand, as far as the VA is concerned, you don't actually have SA until it's DX'd by a Sleep Study. You could have been presenting symptoms for 5/10/15 or 20 Years, doesn't mater, no actual DX, no SA.

Depending how long your symptoms may or may not have been presenting, the SA & P02 drops, have been doing their evil work on your Heart & Brain. Have you had in the past or currently, any Heart issues?

Semper Fi

[EODCMC]

Yea, I had sleep study an DX of mild OSA on active duty in 2002. I elected to not use the CPAP for operational reason. I had a recent study with DX of very severe OSA and I have been using the CPAP since late May. I actually thought I had Alzheimers.  It has helped a lot but not completely. I hadn't talked with the experts yet, I wanted to give CPAP a chance. My previous post in this thread shows both studies and DXs. 

[EODCMC]

OK, the following is my C&P Exam results for Sinusitis and OSA...please comment and offer suggestions:

 

--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT ---------------
                    *************CONFIDENTIAL*************
                    Produced by the VA Blue Button (v12.10)
                               03 Sep 2016

Name: 

------------------------ DOWNLOAD REQUEST SUMMARY -----------------------

=========================================================================
Date/Time:               
Note Title:              C&P EXAMINATION
Location:                VA San Diego Healthcare System
Signed By:               Same Name
Co-signed By:            Same Name
Date/Time Signed:        
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 LOCAL TITLE: C&P EXAMINATION                                    
STANDARD TITLE: C & P EXAMINATION NOTE                          
DATE OF NOTE:                      ENTRY DATE:       
      AUTHOR: GASS,ARNOLD P        EXP COSIGNER: No Entry                           
     URGENCY:                            STATUS: COMPLETED                     

         Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, 
                               Larynx and Pharynx
                       Disability Benefits Questionnaire 

    Name of patient/Veteran:   
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes[ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS

    SECTION I: Diagnosis:
    ---------------------
    Does the Veteran now have or has he/she ever been diagnosed with a sinus,
    nose, throat, larynx, or pharynx condition?  (This is the condition the
    Veteran is claiming or for which an exam has been requested)
    [X] Yes   [ ] No
    
       [X] Allergic rhinitis        ICD code: J30.1   Date of diagnosis: 1994

    SECTION II: Medical history
    ---------------------------
    
    Mr. XXXX is being evaluated with an opinion for direct service connection
    for sinusitis.  During his first three years in the Navy, he worked in a
    paint locker, being exposed to fumes.  He sought medical care.  He then left
    active duty but on reenlistment he worked with explosives and was a diver.  
    Shortly after reenlistment while in Hawaii he developed upper airway
    symptoms problems diagnosed as "sinusitis...acute R" (STR 7May1974) treated
    w/ Actifed but not antibiotics.  During this inital episode he was "out of 
it
    for 2 months."   On 7May1975 he was diagnosed with "stuffy sinuses" and on
    13Jun1975 with a "sinus headache" when he had L retroorbital pain;
    antibiotics were not prescribed.  He listed "hay fever" but commented "no
    known allergies" on a reenlistment SF 93 on 11Jul1980. 
    Environmental allergies were recorded has having had an onset ~1994 (SF 93
    9Dec2000.) 
    A history of "rhinitis for 7 years" with a diagnosis of "allergic
    rhinitis" was noted (10May1999.)  Naldecon
    (Caffeine/chlorpheniramine/paracetamol/pseudoephecrine) was prescribed.  
    He was worked up for allergies by skin testing in 1999 and was diagnosed
    again with "Allergic Rhinitis" in IM Allergy Clinic on 30Apr2001. Treatment
    which had been with Vancenase (beclomethasone) and Allegra-D
    (fenoxfenadine/pseudoephedrine) were discontinued; Nasonex (mometasone) and
    Drixoral (brompheniramine/psuedoephedrine)were begun.
    Symptoms alternate from nostril to nostril.  Of the multiple oral and
    inhaled nasal decongestants which have been prescribed, the most effective
    was Naldecon.  However, when that was discontinued per Navy formulary 
    policy,  his symptoms became more annoying.
    Following separation from the Navy he continued to have "clogggeed sinuses
    on a daily basis."  What he means, is that his nose feels stuffy.  His
    rhinorrhea is thin and watery, not purulent.  Although he feels he has
    seasonal symptoms, he cannot pinpoint a specific season.  He has received
    care from TriCare: his primary medications are psuedoephedrine 60 mg. and
    fluticasone OTC prn.  He continues to have symptoms, sometimes "laying him 
    up or a few days as if I have a bad cold."  During this time he has had
    intermittent courses of antibiotics but none as long as 6 weeks; the longest
    he remembers is 2 weeks.  His last course of antibiotics was prior to exit
    from the Navy.
    He does not have asthma (PFTs were normal in 1999 and 2001) but has eczema.
     A brother has "allergy problems."
    
    
    SECTION III: Nose, throat, larynx or pharynx conditions
    -------------------------------------------------------
    Does the Veteran have any of the following nose, throat, larynx or pharynx
    conditions?
    [X] Yes   [ ] No
    
       [X] Rhinitis

    2. Rhinitis
    -----------
    a. Is there greater than 50% obstruction of the nasal passage on both sides
       due to rhinitis?
       [X] Yes   [ ] No
       
    b. Is there complete obstruction on the left side due to rhinitis?
       [ ] Yes   [X] No
       
    c. Is there complete obstruction on the right side due to rhinitis?
       [ ] Yes   [X] No
       
    d. Is there permanent hypertrophy of the nasal turbinates?
       [X] Yes   [ ] No
       
    e. Are there nasal polyps?
       [ ] Yes   [X] No
       
    f. Does the Veteran have any of the following granulomatous conditions?
       [ ] Yes   [X] No
       
       If yes, check all that apply:
       [ ] Granulomatous rhinitis     [ ] Rhinoscleroma
       [ ] Wegener's granulomatosis   [ ] Lethal midline granuloma
       [ ] Other granulomatous infection, describe:
           
    6. Other pertinent physical findings, complications, conditions, signs,
       symptoms and scars
    -----------------------------------------------------------------------
    a. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs or symptoms related to the conditions
       listed in the Diagnosis Section above?
       [X] Yes[ ] No
       
    b. 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
       
    c. Comments, if any:
       No answer provided
       
    d. Does the Veteran have loss of part of the nose or other scars of the nose
       exposing both nasal passages?: No answer provided
       
    e. Does the Veteran have loss of part of the nose or other scars causing 
loss
       of part of one ala?: No answer provided
       
    f. Does the Veteran have loss of part of the nose or other scars causing
       other obvious disfigurement?: No answer provided
       
    SECTION IV: Diagnostic testing
    ------------------------------
    a. Have imaging studies of the sinuses or other areas been performed?
       [X] Yes[ ] No
       
       [ ] Magnetic resonance imaging (MRI)       Date:
              Results:
              
       [ ] Computed tomography (CT)               Date:
              Results:
              
       [X] X-rays:
           Sinus series.
           
              Date:   3Jan2001
              
              Results:
               FINDINGS:  The paranasal sinuses show normal aeration. 
               There is no evidence
               of mucoperiosteal thickening or bone destruction.  
               
               
               IMPRESSION:  
                
              1.  NORMAL PARANASAL SINUS SERIES.
              
       [ ] Other:
           
              Date:   
              
              Results:
              
    b. Has endoscopy been performed?:  No
    
    c. Has the Veteran had a biopsy of the larynx or pharynx?
    
    No answer provided
    
    d. Has the Veteran had pulmonary function testing to assess for upper airway
    obstruction due to laryngeal stenosis?
    
    No answer provided
    
    e. Are there any other significant diagnostic test findings and/or results?:  
Yes
    
       If yes, provide type of test or procedure, date and results (brief
       summary):
       PFTs 30Apr2001: Normal w/ FEV1 106% and FVC 103%.
       
    SECTION V: Functional imp
act and remarks
    ----------------------------------------
    1. Functional impact
    --------------------
    Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact
    his or her ability to work?
    [ ] Yes   [X] No
    
    2. Remarks, if any:
    -------------------
    Mr. XXXXX's history since 1974 is most consistent with chronic rhinitis, 
both
    perenennial and allergic.  Despite the diagnoses of "sinusitis" in the cited
    STRs, there is no evidence that he ever has had sinusitis.  He does not meet
    criteria for chronic sinusitis (UpToDate.)

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

    OPINION: Direct service connection

    Q: Does the Veteran have a diagnosis of (a) sinusitis that is at least as
    likely as not (50 percent or greater probability) incurred in or caused by
    (the) complaints of and treatment for sinus congestion during service?
    A: No.

    Evidence reviewed: Tab A (STRs in VBMS): Service treatment records noted 
with
    sinusitis dated 09/06/1983 and 04/07/2001.
    Tab B (STRs in VBMS): Physical exams noted with sinusitis dated
    12/01/2000.
       Other STRs cited in Medical History above.
       
    Rationale: Mr. XXXX's history is most consistent with chronic rhinitis 
w/out
    evidence of sinusitis by imaging (2001.)  He has never been treated with a
    prolonged course of antibiotics; in fact, most of the time even a short
    course of antibiotics has not been prescribed.  Treatment has been with
    antihistamines, inhaled corticosteroids, and decongestants.  The two most
    complete evaluations (1999 and 2001) explicitly diagnose "allergic 
rhinitis,"
    not sinusitis.
    Since he has nasal obstruction by my exam as well as a prior sense of
    fullness, the fullness is mainly a stuffy nose, not a sense of sinus 
pressure
    or fullness.  Thus although his symptoms are suggestive of chronic
    rhinosinusitis (CRS,) he has not had confirmatory imaging or endoscoptic
    examination, two studies which are required to confirm the diagnosis of CRS.
    The only study he had, a sinus series done in 2001, although not the most
    sensitive test for CRS, was not even suggestive of a sinus condition.

    Therefore, it is my opinion that Mr. XXXXX has chronic rhinitis, both
    perennial and seasonal (allergic,) but not sinusitis.  The rhinitis is at
    least as likely as not (>/= 50% probability) incurred during service.
    

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

                                   Sleep Apnea
                        Disability Benefits Questionnaire

    Name of patient/Veteran:  James Edward Conti
    
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes   [ ] No
    

    ACE and Evidence Review
    -----------------------
    Indicate method used to obtain medical information to complete this 
document:
    
    [X] In-person examination
    

    Evidence Review
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS

    1. Diagnosis
    ------------
    Does the Veteran have or has he/she ever had sleep apnea?
    [X] Yes   [ ] No
    
       [X] Obstructive
              ICD code:  G47.33              Date of diagnosis: 2002

    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's sleep
       disorder condition (brief summary):
         Mr. XXXXX is being examined with an opinion for direct service
         connection for sleep apnea (OSA.) During his second enlistment he 
snored
         quite loudly - "It hurt my operability because, when I went on field
         ops, the enemy could hear me!"  Subsequently his wife complained of his
         snoring; she also noticed apneic spells.  They slept in separate rooms.
         Therefore, a sleep study was done (4Jun2002.)  This showed mild sleep
         apnea (AHI - 11.7.) A palatal procedure was suggested (23Aug2002) in
         Otolaryngology Clinic but, when he heard of the side effects, he
         declined the operation. CPAP was prescribed but he declined usinc it
         since he could not take the machine on a mission.
         At separation he weighed 204 pounds but chose not to apply for
         benefits at that time.  Regarding treatment, "I forgot about the CPAP
         part.  I did not want to use a machine.  My snoring did not bother my
         wife as much."  His new PCP, concerned about headaches on awakening,
         easy irritability, daytime hypersomnelence, cognitive problems and
         non-retorative sleep, ordered a sleep study (3May2016) which showed
         severe OAS (AHI 38.0.)  CPAP was precribed immediately. He can tolerate
         the mask.  He is using it. "I feel like a wet blanket was taken off me
         but I still have problems remembering names."
         
    b. Is continuous medication required for control of a sleep disorder
       condition?
       [ ] Yes   [X] No
       
    c. Does the Veteran require the use of a breathing assistance device?
       [ ] Yes   [X] No
       
    d. Does the Veteran require the use of a 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?
    [ ] Yes   [X] No
    

    4. Other pertinent physical findings, complications, conditions, signs,
       symptoms and scars
    -----------------------------------------------------------------------
    a. Does the Veteran have any other pertinent physical findings,
       complications, conditions, signs or symptoms related to any conditions
       listed in the Diagnosis Section above?
       [X] Yes   [ ] No
       
           If yes, describe (brief summary):
              Ht: 5'11"; Wt: 270#. BMI:  Neck circ: 19-1/2"; 49.5 cm.
              Oropharynx: large obstructing tongue, small oropharyngeal 
diameter.
              Palate not redundant or particularly dependent.
              
    b. 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
       
    c. Comments, if any:
       No response provided.
       
    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:  2002; 2016
           
           Facility where sleep study performed, if known:  2002: Naval Medical
              Center SD (Balboa.)  2016 Sleep Data, SD.
              
           Results:
             2002 AHI - 11.7 (mild OSA.)  2016 AHI 38.0 (severe OSA.)
             
    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?
    [ ] Yes   [X] No
    
          
    7. Remarks, if any:
    -------------------
    Mr. XXXXX has OSA, first diagnosed definitively in 2002 (mild) and
    reconfirmed in 2016 (severe.) 

    MEDICAL OPINION REQUEST

    TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

    OPINION: Direct service connection

    Q: Does the Veteran have a diagnosis of (a) sleep apnea that is at least as

    likely as not (50 percent or greater probability) incurred in or caused by
    (the) complaints of and treatment for breathing difficulty and sleep apnea
    during service?
    A: Yes.

    Evidence reviewed: Tab A (STRs in VBMS): Service treatment records noted 
with
    sleep study 
    diagnosed with mild sleep apnea dated 06/04/2002 and 03/20/2003.

    Rationale: Mr. XXXXX had symptoms consistent with sleep apnea during active
    service.  A sleep study (4Jun2002) confirmed OSA and this diagnosis was
    entered on a progress note "Separation from Active Duty" (20Mar2003.)
    Therefore, the Veteran's sleep apnea was at least as likely as not (>/=50 %
    probability) incurred during service.
    Risks for sleep apnea include age, gender, and weight.  Mr. XXXXX was 17
    years old and weighed ~142# at entry into the Navy; at discharge in 2003 he
    was 50 years old and weighed 204#.  Never-the-less the fact remains that a
    sleep study in 2002 was +ive and consistent with his symptoms.
    At the time of his current sleep study (3May2016) he was 62 years old and
    reports weighing ~250.  Clearly age, weight gain, a neck circumference >18",
    and a small oropharynx with a large tongue all contribute to his
    sleep-disordered breathing and have contributed to his progressing from mild
    OSA (AHI 11.7) in 2002 to severe OSA (AHI 38.0) in 2016. He has benefitted
    from CPAP but would do even better should he be able to lose weight as he
    plans to do.

    Conclusion:  Mr. XXXXX has a diagnosis of obstructive sleep apnea (OSA) that
    is at least as likely as not (>/= 50% probability) incurred during service;
    confirmed by sleep study 4Jun2002.
    

 
/es/ XXXXX, MD
ACOS/ECS
Signed: 
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