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.

[Gastone]

That's a 50% SA Rating every time. Interesting, no discussion of your low P02's and need for Supplemental 02, just indicates dropping lbs would help your symptoms.

You really need to address your P02's with your Sleep Dr. I'd file a SA FDC Increase as soon as you get the SA Award Letter. You need the Supplemental 02 DX ASAP.

Semper Fi

[Buck52]

I agree Gastone  but the 50% rating is getting ready to go out the window and VA is cracking down hard on the S.A. Criteria in the M21-1MR From April 2016

So 

if you are trying to service-connect sleep apnea….act NOW…before things get crazier inside the VAMC.

Ask your doctor for a letter stating that your CPAP (or other breathing assistive device) is medically necessary to treat your Sleep Apnea.

Even if you are already service connected, it makes sense to get that “medical necessity” letter now.

Why?

If history is a good predictor – and it usually is – the VA is going to start proposing a shit-ton of rating reductionsfor VA Sleep Apnea claims where there is no evidence of medical necessity already in the C-

Source: chris Attig   VL Blog

[EODCMC]

Gastone and Buck, thank you very much for taking the time to review my information. I understand all and fully agree. I was immediately concerned about the P02 levels. I was a Navy diver for 25 of my 28 years. I know how important the oxygen partial pressures are.

I'm dismay to hear that the VA is looking to make negative changes to SA. I havnt read this anywhere. I suppose I could ask my doctor support it should the VA make some negative decision, but not before. I mea, they should feel that their DX already states the need, right? Is the 50% rating going away and do you think it will be retroactive?

I have questions about the Sinusitus. It seems to me that the VA Doctor essentially stated that all my previous DXs by numerous doctors were misdiagnosed. And, because I did not show the appropriate symptoms on the day of the C&P, that I don't have chronic Sinusitis. Just from looking up my nose in a half hour interview? Do I have grounds to appeal?

Also, because he diagnosed me with chronic Allergic Rhinitis, does that mean I can receive compensation for this or do I need to submit another new claim? There are numerous DXs of this in my SMR also. 

Again, thank you. I really appreciate your help.

[Gastone]

What were the C & P Dr's Credentials, GP or ENT?

If in fact his IMO regarding your Rhinitis as a DX vs Sinusitis, is accepted by the Rater, it would become a Comp Claimed condition. No New Claim would have to be filed, if SC'd, a separate Rating would be assigned per the 38 CFR 4.

The C & P Dr was very adamant in his DX discussion. "Never any Medical Evidence of Sinusitis, Always Rhinitis."

Did you receive a DX and treatment by a Navy Dr, ENT Specialist?

Semper Fi

[Buck52]

EODCMC

The change is forthcoming for S.A. Claims   its in the works now  and the VA is going to make it harder for S.A. Claims and reduce the 50% criteria they have now,going to make the criteria harder, what veterans need to do is have  more documentations about their S.A. ..If your denied   having more medical documentation from a Dr opinion will help in Appeals , even a sleep disturbance while in the military  will be hard to prove S.C. to Sleep Apnea , its getting to where you need a sleep specialist to give his/her opinion on your S.A. and a Rational  to S.C. it (thats how it is now yes)  but the VA is going to add a lot of provision in their favor and not the veteran.

I understand they will Montier at random S.A. Claims after approve with the SIMS Card in the C-PAP...Bi-PAP's  if its not being used a certain %  then this will create a Proposal to reduce.

 C-Paps & Bi's Have a second ''hidden'' sims card, after they take the first one out, there's another  hidden sims card in the machine that keeps recording data.

Reason I know this is a VA Sleep tech mention this to me.

what the changes will be I don't know, like I mention  its all still in the works. probably next year some times? as for as for as S.A. Claims now it is still the same with the 50% rating  so your safe.

Edited September 5, 2016 by Buck52

[EODCMC]

Gastone, the only information that I have on the Dr. Is what I posted. During our chat I got the impression that he was a GP. Well, then I can't imagine getting more than 10% for Allergic Rhinitis. If I'm correct that should mean 55% if the SA and AR are combined, right?

Buck, that is will major cause of concern. Is SA a static condition. I haven't read anyplace where SA has been cured.

I use the CPAP every night. I can't imagine not using it...It really works! It can be ill fitting when you don't change out the mask and readjust the straps regularly. I purchased the SoClean. This machine makes 02 cleaning the machine a snap. No more soap, water and drying. 

Again, thanks for your' help and advice!