Before I NOD, seeking input on SC sleep apnea

[Marine1342]

Hello HadIt Community,

TL:DR
Skip down to bold section “So that brings us to today….”

I've been a bit of lurker on the forums, searching and researching information already presented, hence the lack of postings.
I was not quite sure where to post this, in the “Appeals” section or the “Disability and Claims” section.”  I decided on the “Appeals” section due to the fact that the claim was already submitted and decided on, and so the next step logically would be an appeal.  Moderators, if it needs to be moved, please move it to the correct section.

I know that there is a lot of postings, questions, and information in regards to sleep apnea and trying to get it service connected, namely to PTSD and/or TBI.  I hope that by sharing my path/progress it will help others who are in a similar situation.

I am SC for TBI (70%), PTSD (50%), Mechanical neck pain syndrome (10%), tinnitus (10%).  Total combined rating with fuzzy math puts me at 90%.

This path of medical issues and nuances began in 2007 when I was in the Marine Corps, and it has taken my up until this year to really get most of my issues addressed and sorted.  What delayed the entire process would be attributed to not knowing the secondary effects to injuries.  Certain things were obvious (a head injury has secondary consequences like memory issues), but other things (namely the PTSD) were not.  The VA, for me, has done an excellent job in diagnosing things, as well as the therapy afterwards.  I know that this is not the case for everyone, but I was persistent and proactive towards trying to learn about myself and the changes I was going through and had been through.  Not having considered PTSD as a problem for me (denial maybe?), I had attributed everything (headaches, poor sleep, attention problems, behavioral changes) to the head injury.  Turns out that a lot of the symptoms of TBI are shared with PTSD, making treatment harder.  Is the poor sleep because of the head injury or the PTSD? If the memory and lack of focus because of the head injury or the PTSD, etc.

It took me a year and a half, after 6 months of initial therapy, to go through the medicine trial run.  Try different medications, see if I feel any different.  If I do, do I feel better?  Once the right medicine is found, then it’s about finding the best dosage for me.  Because everyone is different, and we are all wired differently, no 1 chemical will react the same way for everyone.  At times, it felt that nothing was really working, and it didn’t help that the trial period takes time for your body to adjust to the new drugs.  But with an open line of communication with my psychiatrist made it easier to track changes and make the changes so that I felt better.  For me, it’s been a night and day difference.  Looking back and remembering how I felt, it was almost as if my brain was in a constant fog.  I was awake and aware of things, but almost as if things were in a dream-like state.  I don’t know how else to describe it, but it felt like the drag I had on my mind and shoulders was eased.  There are still bad spells and moments, but that is where the discipline and focus really comes into play.  It hasn’t been easy, and I can’t even begin to imagine how it is for those who have a bigger challenge than I.  But what I do know, is that you need to be wanting to make things better for yourself.  It’s a bit of a process.  Therapy isn’t the easiest, as you need to revisit certain areas in your life that you don’t want to.  It takes time, and you feel quite low during certain times.  In some ways, it allowed me to learn more about myself, and what I needed to do and go through to make myself better (know yourself and seek self-improvement…).  But it gets better, I promise.

Biggest takeaway from disability claims with the VA, is to make sure you have your paperwork in order BEFORE you submit things.  At the beginning I did not know what I had, how the VA system worked, or anything at all.  So my first claim consisted of:  neck pain, lower back pain, headaches, memory problems.  Very broad and generic symptoms.  They were denied, but through the intake process, I did learn that I should talk to the VA clinic, namely the poly-trauma area to have my TBI assessed.  From there, it was evaluation after evaluation to try and get an answer as to why I was having problems.  TBI led to tinnitus and neck problems.  TBI therapy then lead to depression screening which led to PTSD screening.  PTSD screening then led to therapy.  Once those two main areas (TBI and PTSD) were stable enough for me, I started to address other issues, namely sleeping problems.  Headaches every day when I wake up, cold sweats every other night (changing sheets couple time a week….), nightmares.  I had attributed all those symptoms to the head injury, but that was when I had learned that it could be partially the head injury, and partially the PTSD.  More research lead to asking for a sleep study done.  I figured that if there is something going on while I sleep, maybe it’ll show up on the results and give me a better idea to what’s going on.  Having a better idea, it would allow me to attack the problem from a different angle.

I found that throughout the entire VA process (starting in 2007), the best way to tackle things is to focus on it like a puzzle.  Define the problem, get a better idea of what it is, and this then leads to knowing how you can attack it head on. 

I don’t know what exactly I was expecting out of the sleep study, but I certainly did not think that I would have an issue with breathing while I sleep.  I had assumed that my combination of injuries was manifesting itself while I was sleeping (my most relaxed state).  Long story short with my sleeping habits from the past, the sleep study showed that I had mild sleep apnea, namely obstructive sleep apnea.  CPAP machine was then issued.
Now to me, that didn’t make any sense at all.  I don’t fit the OSA poster-boy, at all.  Overweight?  Thick neck? Older? I’m 28, 6’, 165 lbs.  But I had some answers.  My shallow breathing would cause decreased oxygen intake which causes an increase in CO₂ in my blood.  Heart pumps faster, fight/flight response starts, body is working harder to supply blood to muscles, cold sweats start to try and dump CO₂.  Then I wake up and I have to go use the bathroom, 1-2 times per night.  I just figured I was well hydrated…haha…

With the answer of sleep apnea of the obstructive kind, I started to research causes for it, and correlations to different injuries.  One thing leads to another and there are correlations between head injuries and PTSD.  So at that point (more answers…yay), I go back to VA research and learn that there can be claims filed for OSA.  Since I was diagnosed with OSA outside of service, then I would need to either prove it happened while I was in (no evidence, so scratch that), or have a secondary connection to a service connected disability.
Seeing that I was SC for TBI and PTSD, that would be the route I would take.  What this meant was that I would need to present information to the VA showing a correlation between the injuries, and have the weight of a doctor behind it.
I made sure to file an Intent to File notice so that my date was locked in for retroactive pay.
With this date locked in, I needed to go about finding information on IMOs.  Researching and learning, I decided to go with Dr. Anaise and get an Independent Medical Expert Opinion.  $1500 later I had a nice sizeable book with him stating (and with evidence too) that he opined that it is more likely than not that my sleep apnea is secondary to my service-connected PTSD, TBI and tinnitus. 
With my new information and medical opinion in hand, I submitted a Fully Developed Claim, since I had no more information to submit (IMO from private doctor, and the VA had all my medical records including the sleep study).  6 months of waiting and checking eBennies (torture….) and it finally finished and showed that a decision had been made.  Paperwork comes in the mail and the claim is denied…

Frustrated? Not really, since I had expected that it would be denied.  Most claims, unfortunately seem to be denied the first time around.  Bit let down sure.  But it is what it is, I can’t change that, so now time to look at how to keep pushing forward.

 

 

So that brings us to today….
I do plan to submit a Notice of Disagreement to have it reviewed again.  I have been told that the reviewal process is in the time length of 2-5 years (frustrating but backpay will be nice…).
 

My posting on HadIt is based on wanting to get other people’s input and a fresh set of eyes on the information I have and what the next steps are, different viewpoints, and maybe anything I missed/am missing, as well as posting my information and path on here for others to read and learn from.

Medication:
Venlafaxine 300mg for PTSD
Zolpidem Tartrate 5mg for sleep (Ambien)

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VA Decision letter verbatim:

Issue/Contention

• sleep apnea

Explanation

• The evidence does not show that sleep apnea is related to the service-connected condition of traumatic brain injury, nor is there any evidence of this disability during military service.

• Service connection for sleep apnea is denied since this condition neither occurred in nor was caused by your service.

• Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.  The evidence does not show an event, disease or injury in service.  The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability.  The VA examiner stated that your current sleep apnea is due to the airways in your throat relaxing too much to allow normal breathing and closure of your muscles than your service connected TBI, tinnitus, and/or PTSD.

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VA Examination
I was not there for the exam because verbatim:
[X] 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.

 

Verbatim:

MEDICAL OPINION SUMMARY

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opinion ---OSA 2/2 to PTSD

LESS LIKLEY THEN NOT THE OSA IS 2/2 TO PTSD --

RATIONALE --OSA IS A OBSTRUCTIVE DEFECT Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula ? a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood and cause a buildup of carbon dioxide. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it. You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long.

These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours. People with obstructive sleep apnea may not be aware that their sleep was interrupted.

In fact, many people with this type of sleep apnea think they slept well all night

 

/es/ *Name removed* FNPC

PRIMARY CARE PROVIDER

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IMO excerpts verbatim

“After reviewing the veteran’s c-file and the pertinent recent medical literature, I opine that is more likely than not that the veteran’s sleep apnea is secondary to his service connected PTSD, TBI and tinnitus”

“After reviewing all of the veteran’s medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is secondary to his service-connected PTSD and TBI.  The scientific observation that the derangement of REM sleep prominent in the PTSD patient is the cause for sleep apnea is of particular importance in this case.  It is more likely than not that the veteran’s sleep apnea is secondary to his service-connected tinnitus.”

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The report is 7 pages long with 5 5 exhibits of evidence (scientific journal reports).  If needed for better clarity, I can scan the 7 pages in (edited for privacy).
I can also post the findings from the sleep study if needed as well.

 

I don’t want to provide my thoughts and input on this just yet, as I would like to see what the community’s thoughts are on where things are so far, based on what there is.

What I ultimately am looking for, besides getting my claim granted, is to gain a better idea of what route I should take based on what I have.  The VSO who I was working with suggested a simple medical statement that says my medication for PTSD affects my OSA (throat muscles relaxing), was also recommended to have a DRO review the case (instead of a RO?) since it might speed up the process because it was more ‘in-house’. De Novo review? CUE?

Thank you in advance for your thoughts, view points, and suggestions

 

 

The CPAP machine, took a bit of time getting used to, but it is a night and day different (no pun intended ha).  The nightmares are less, the cold sweats are essentially gone, morning headaches aren’t there, and I feel rested now when I wake up and throughout the day.  Getting sleepy while driving isn’t there anymore.  I wanted to see its effectiveness, so I decided to try sleeping 2 nights without the mask, and the first night, instantly the prior symptoms came back.  Headaches, cold sweats, over tired all day.

 

My conclusion, from my personal experience, is that if you have PTSD, TBI or both, get a sleep study done.  There is strong enough correlation between the three to have symptoms overlap and exacerbate one another.  I may not know the exact scientific workings behind it, but logically it makes sense.  PTSD or TBI, get testing and therapy done to better understand the challenge that YOU have, and how to better work through/around/over it.  If they recommend medication, ask why.  Not to push back against it, but so that you understand what the purpose of it will be, how it will help you.  Self-knowledge and self-learning are very important in order to have a better grasp of things pertaining to you.
Be patient with medication, and be honest with your prescribing doc.  Everyone reacts differently to medication, and only YOU can determine how you feel.  I might even recommend keeping a small journal of how you FEEL throughout either therapy or medication trials.
Be patient with your meds.  Medicine doesn’t work overnight, especially finding the right one and dosage.
Be patient with therapy.  Not during therapy necessarily, but in the length of things.  It takes time depending on severity.  You will feel worse some days more than others.  Therapy, like medicine, is unique to YOU.  What worked for me, may not work exactly (or at all) for you.  But you need to be honest with yourself and with your guides (therapists and docs).

I had a small ‘good luck charm’, a grounding tool, that I would touch and hold when my mind would start to wander.  Helped to keep/bring me back to reality.  Grounding techniques worked wonders, but you need to be disciplined about it.  My good luck charm was a 550 cord bracelet I made when I was in.  Feeling the knots and mentally talking to myself kept me ‘here’.  Doesn’t have to be something big.  Just a small item that has meaning and significance to YOU.  You don’t even have to tell people what it is or does or anything.
But it gets better, I promise.

[Marine1342]

James:

Yeah...that is about half of it.  Granted the other half was all the supporting document.  It took me a while of reading (and re-reading) to understand what he was saying in the IMO.  It was a lot for the rater to read, so I can see why they may have just passed the buck.  Not saying they were right in doing that, but makes sense.

From my findings, I figured it would be better to have more since they might end up saying well there is no supporting information on these statements made by the doctor etc.

The qualifications of the C&P Examiner were that they are a NP (Nurse Practitioner).  The signature stated FNPC, which google stated it means Family Nurse Practitioner - Certified.  So the fact that I was not there, and that it was done by a nurse practitioners against a doctors statement, I feel like that has a significant weight in my benefit.

In regards of having the C&P exam redone, you stated to ask that it be repeated with my being present.  As in you, James, or me Cisco the vet present?
With that being said, if I ask for a reconsideration at the regional level, would it make sense to ask for the C&P exam re-done? Does one impact the other?

I'm going to circle back to that process and what it looks like, as soon as I address the other posts as well.

[Marine1342]

Gastone:

Case decided, I'm fracked, BVA hearing 3-5 years down the line...that's what I had figured.  Never is quite easy the first time around.

Medical credentials for the C&P Dr. was a nurse practitioner - certified, from my findings.  Need to do some more research, but doesn't look like they were a medical doctor.  The rater said that the IMO was evidence considered, but never mentioned it or anything.  C&P doctor gave the definition of obstructive sleep apnea and then that was it.  So maybe it was 'considered'

How did you go about finding a MD board certified SA specialist?  I've never had to go through specific doctor finding for myself or family members so this is news to me.  Or at least where/how to look.

And no, I did not submit for the ED SMC - K.  Was focusing on this since it had more importance in comparison, I think.

[Buck52]

I would submit a NOD AND REQUEST DRO Hearing  or Reconsideration  as James cripps mention get a specialist to nexus this, he/she would trump that C&P PA. By what they call  equipoise factor and usually is favorable for the Veteran. 

by all means try to get this decision from your R.O.

JMO

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

[Buck52]

One reason or a big reason to file all your claims and not wait is to get that EED going  rather or not your denied ,  when you do win they go back for your retro pay to date you filed or in some cases the date the disability arosed or  first started.

[jamescripps2]

Marine,you need to be present at the C&P exam, not myself.

The rater calls for the C&P exam. The request goes to the VA medical center. The medical center schedules the exam. The medical exam is preformed by the medical center or subcontracted out to QTC, just depends upon where your medical center is located. Any complaints by the veteran are to be addressed to the patient advocate of that medical center.

[Gastone]

C & P Review of all your "Med Evidence of Record" by a NP seems in my Lay opinion to not quite "Cut the Mustard."

It's not unusual for the Rating Dept not to require an Actual C & P Exam with the Veteran present, if it is determined that the "Evidence of Record" is adequate and no additional C & P Exam is necessary, just a Qualified Clinician's review.

Keep your NOD Locked & Cocked, give some quick consideration to filing an Immediate "Official Request for a CUE Review" of your recent Decision based on your Medical Evidence of Record.

That worked for me recently 05/16 File the "CUE Review" of a 12/15 Decision, New EED Award Date issued 07/16. I was getting ready to file my NOD.

Check local Hospital Sleep Dept for MD Neurologist Board Certified Sleep Specialist. One appointment could seal your DEAL. Don't actually need a DBQ, just his Clinician Notes addressing your SA Nexus should do the trick. Of course, that presumes he agrees with Yours and Dr Anaise's Etiologic theories.