Jump to content
VA Disability Community via Hadit.com

VA Disability Claims Articles

Ask Your VA Claims Question | Current Forum Posts Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users

  • homepage-banner-2024-2.png

  • donate-be-a-hero.png

  • 0

Before I NOD, seeking input on SC sleep apnea

Rate this question


Marine1342

Question

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)

--------------------------------------------------------------

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.

------------------------------------------------------------------------------

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

-----------------------

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

--------------------------------------------------------------------------

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.”

---------------------------------------------------------------------

 

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.

Link to comment
Share on other sites

Recommended Posts

  • 0

It is a fact that insulin injections cause weight gain problems. Another fact is that, yes, some VA doctors will be very adamant as to the cause of the OSA. If you expect a VA doctor to write you a letter then you need to know how to ask for it. Don't be meek, but rather confident and assertive. Ask for what you want.

 

Link to comment
Share on other sites

  • 0

Bit of an update (and to verify my learned knowledge is correct on this) to add information and clarity to this thread for those that read it.
And please let me know if I am correct in what I wrote.  If not, let me know so I can edit the information.

Following the Notification letter denying a claim, the next options (excluding doing nothing) would be:
- Request for Reconsideration (also called RFR or to re-open a claim)
- Notice of Disagreement (NOD)

"A request for reconsideration is nothing more than a reopened claim.  You must have new evidence to support the request.  You are essentially telling VA that you aren't disagreeing with the decision that was made based on the evidence VA had, but you want to submit some new evidence now that you think will change the decision.  Like I said, it's just a reopened claim and since reopened claim generally get processed faster than NODs you can usually get a decision faster, and any decision that is based on new evidence submitted within the one year appeal period of the claim in question preserves any potential earlier effective date.
The downside to requesting reconsideration instead of submitting a Notice of Disagreement is that if the decision isn't made within the one year appeal period you will have lost any chance to appeal the first decision if you don't get a favorable decision on the request for reconsideration.  This is why as a VSO I rarely request reconsideration.  I only do this when I am absolutely positive of the outcome of the claim and I'm not usually absolutely positive of the outcome."
- Cruiser http://vets.yuku.com/reply/389598/Request-for-Reconsideration#.WBPD02zrtPZ

The request for reconsideration, which normally is done at the Regional Office (RO) level, means that they will review your file again, based on new evidence that was submitted.  Hence, they are re-opening your claim.

A notice of disagreement, must be filed within 1 year of the decision date.  You don't have to submit new evidence, but more evidence (good evidence in your favor of course) is always better.  So if you got it, submit it either way.
Downside to a NOD is that it does take longer than a regular decision, longer than a re-opened/RFR claim, but less than a BVA level claim.

So my take on this, depending on how much time you have left on that 1 year NOD limit, and how sure you are of a favorable outcome, it might be faster to submit new evidence so that you get that RFR/re-open claim.

If the RFR/re-open claim route is taken, you have 60 days (or is it 90?) to submit the new evidence in support of your claim.  So balance of time is critical here.  Don't wait to long that you risk the RFR overlapping the NOD limit, but also don't do it so early that you can't get your new evidence (IMO/IME, in-service book/statements etc.) completed and sent in time.

Link to comment
Share on other sites

  • 0

Bumping this up.

Been doing some research and I've read that if the claim gets denied on the first go around, that before you submit a NOD or go that route, that a Vet should hire a lawyer/attorney to help with the process.  Given my situation, would you recommend I go this route?  Maybe wait till after the request for reconsideration?

Also, please see previous post for information accuracy, and let me know if it would need to be corrected.

Link to comment
Share on other sites

  • 0

At Ease, on the Attorney. You may end up actually having to hire one, just be sure it's necessary, why lose the 20% of your Retro due to Premature EJ----tion.

Point me to your OSA Claim, timeline. Did you post it on the previous 6 pages?

Have you requested the "Official Reconsideration" yet? If not, your waiting for, what?

Semper Fi

Link to comment
Share on other sites

  • 0

Gastone:

Thank you for the clarification on the lawyer.  Just wasn't sure if that was something that was needed now or later.  But if and when I need it, I'll look up the legal help on it.  No sense in losing retro if not needed.

The OSA Claim timeline wise, the Letter of Decision Notification letter (dated September 14, 2016) stated that my claim was for sleep apnea was denied.  So I have 1 year from that date to either NOD or Request for Reconsideration (with or without new evidence). Posted prior was the reasoning for the denial, who the C&P Examiner was and their credentials (Nurse Practitioner), as well as the evidence I submitted (my nexus letter by Dr. Anaise).  Page 4 and Page 5 of this thread has the information (files attached) as well as a bit more explanation.

In regards to requesting and "Official Consideration", I need to get in touch with a VSO, the one I was working with left, and the one that was recommended hasn't returned communication.

It was recommended on this thread that I should look for a doctor (preferably that is board certified sleep) to hopefully concur with the Dr. Anaise nexus letter and get a second nexus letter, in order to help support my claim.  And this is where it gets a bit hazy for me, and maybe you (or others) can clarify.  In order to do an "Official Reconsideration" what form is to be used for this? Having a bit of trouble locating a board certified doctor, so wondering if either 1 other nexus letter (Ellis Clinic maybe?) or maybe even the nexus letter I have from Dr. Anaise is enough, for my particular case?

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  

The other part, I just want to confirm the accuracy of information.  This is more for reference information on this thread, for those that are following this or might need to reference it later for themselves in regards to filing a claim that is denied and then options and knowledge:

On ‎10‎/‎28‎/‎2016 at 4:46 PM, Marine1342 said:

Bit of an update (and to verify my learned knowledge is correct on this) to add information and clarity to this thread for those that read it.
And please let me know if I am correct in what I wrote.  If not, let me know so I can edit the information.

Following the Notification letter denying a claim, the next options (excluding doing nothing) would be:
- Request for Reconsideration (also called RFR or to re-open a claim)
- Notice of Disagreement (NOD)

"A request for reconsideration is nothing more than a reopened claim.  You must have new evidence to support the request.  You are essentially telling VA that you aren't disagreeing with the decision that was made based on the evidence VA had, but you want to submit some new evidence now that you think will change the decision.  Like I said, it's just a reopened claim and since reopened claim generally get processed faster than NODs you can usually get a decision faster, and any decision that is based on new evidence submitted within the one year appeal period of the claim in question preserves any potential earlier effective date.
The downside to requesting reconsideration instead of submitting a Notice of Disagreement is that if the decision isn't made within the one year appeal period you will have lost any chance to appeal the first decision if you don't get a favorable decision on the request for reconsideration.  This is why as a VSO I rarely request reconsideration.  I only do this when I am absolutely positive of the outcome of the claim and I'm not usually absolutely positive of the outcome."
- Cruiser http://vets.yuku.com/reply/389598/Request-for-Reconsideration#.WBPD02zrtPZ

The request for reconsideration, which normally is done at the Regional Office (RO) level, means that they will review your file again, based on new evidence that was submitted.  Hence, they are re-opening your claim.

A notice of disagreement, must be filed within 1 year of the decision date.  You don't have to submit new evidence, but more evidence (good evidence in your favor of course) is always better.  So if you got it, submit it either way.
Downside to a NOD is that it does take longer than a regular decision, longer than a re-opened/RFR claim, but less than a BVA level claim.

So my take on this, depending on how much time you have left on that 1 year NOD limit, and how sure you are of a favorable outcome, it might be faster to submit new evidence so that you get that RFR/re-open claim.

If the RFR/re-open claim route is taken, you have 60 days (or is it 90?) to submit the new evidence in support of your claim.  So balance of time is critical here.  Don't wait to long that you risk the RFR overlapping the NOD limit, but also don't do it so early that you can't get your new evidence (IMO/IME, in-service book/statements etc.) completed and sent in time.

 

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...

Important Information

Guidelines and Terms of Use