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Question

Okay so my C-file arrived, and did so amazingly  fast. Less than two months, not bad time.

Going through all the files and sorting them but one of the first things I need to get together is the claim on OSA.

I know the rules have changed about OSA ratings and now the med file must have a doctors saying specifically OSA is a medical condition

From the MR21-1MR

“When determining whether the 50-percent criteria are met, the key consideration is whether use of a qualifying breathing assistance device is required by the severity of the sleep apnea.”

“Use absent a medical determination that the device is necessary does not qualify.  The regulation requires that the device be necessary and this is a medical question.” 

So here is my situation.

On 07/07/2013 I had my initial PTSD C&P which noted serious sleep problems, chronic fatigue, hypersomulance but it did NOT mention the SLEEP STUDY diagnosis given on 4/13/13

At that time the simple issuance of a CPAP was considered sufficient to getting a 50% rating for OSA, but as the change listed above notes that is not the case now.

I have already filed a claim for OSA secondary to my PTSD. I did this before my Review C&P for PTSD exam, which resulted in getting bumped to 100% PTSD P&T.

With the change in MR21, I suspect they may disapprove the OSA claim.

If they do, would my path be to file a CUE because the record showed the apnea existed and a cpap was issued when they rated me for PTSD.  The retro pay would be awesome!

That would seem to be an error on their part and under the old standard I would have gotten a 50% rating for OSA as well as my 70% for PTSD and 10% for Tinnitus. The 70+50+10 calculation is 87 which rounds up to 90 for pay purposes and getting that retro 20% difference for 60+ months would be a nice holiday or new years present to me 🙂

In the alternative, would I submit a NOD with the same information?

or would I have to get a DOC to say that the CPA was medically necessary and would that mean I needed another Sleep Study?

Thanks in advance. I am just trying to get things ready for whenever they make a determination on the existing claim.

Edited by GeekySquid
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17 hours ago, GeekySquid said:

At that time the simple issuance of a CPAP was considered sufficient to getting a 50% rating for OSA, but as the change listed above notes that is not the case now.

I should have also noted that on the Epworth sleepiness scale i am rated at 20/24, which is not a good thing. The sleep study result shows I get very limited amount of rest and very little REM sleep.

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