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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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NoZZZ's

IMO for Sleep Apnea/cervical - where to get one?

Question

Hello All,

I am planning on filing a claim for sleep apnea, which was not diagnosed while I was on active duty, as well as cervical pain and Allergic Rhinitis, which were noted in STR's but not officially diagnosed until a few years later, despite continuous treatment for them by the VA. While there is some reference to sleep issues while I was deployed, and treatment records in service for the other two, I want to make my claim as strong as possible from the start.

Having read through many of the posts here and elsewhere regarding the nexus to service connection, I believe I will need an IMO to connect the in service event (injury on deployment) and my current diagnosis for sleep apnea, since it was diagnosed about 9 years after I left active service. My spouse is willing to write a statement regarding the symptoms she has witnessed since I left service until my diagnosis, and I have had two sleep studies confirming a diagnosis of sleep apnea (both done at the VA, 6 years apart).  I plan on trying for direct service connection (unlikely but worth a shot) as well as secondary service connection (I have other SC conditions, but only rated at 20%, to connect it to). The pulmonologist at VA said my chronic pain likely contributes to my sleep apnea, but I am guessing this is not affirmative enough language for the  VA rater, which is why I plan on seeking an IMO, for all three issues I am claiming.

My primary care Dr is at the VA, and tends to write in generalities, so I don't think she will be a good choice for writing the IMO/DBQ (she tells me I have to wear my CPAP or I will stop breathing or die in a car accident, but only writes in my chart that "CPAP is recommended"). I have been looking (unsuccessfully) online for doctors who specialize in providing IMO's, and have read about the ones reviewed here, but was wondering about another I keep seeing pop up in the google searches - VA Claims Insider. Seems like a one stop shop, but I have not found much information about them other than what is offered on their website and Youtube channel.  Also, the idea of paying after a claim increase seems like a good option, since multiple IMO's can be expensive, but I would think this could present a conflict in the eyes of the VA, since the fee increases with the size of the award.  Also, I'm not going to lie, I think it would be great to have someone go over my records and possibly identify issues that I can rightfully claim that I am just not aware of. That seems to be the service they also provide, along with IMO's.

So, any guidance or reviews would be appreciated.  I am pretty confident that I will need the IMO's. I just don't know where to get them without a potentially awkward first visit to a new Dr, "Hi, I know that we just met, but can you write this very detailed letter for me so I can get disability compensation. No pressure."

Thanks, and thank you all for the great info on this site.

P.S. - I do not intend for this to become a thread to bash one service over another, or to endorse any particular service. I would just like some honest opinions about any of the people you folks have used. The nexus letter seems to me to be the deciding factor in many of the BVA appeals I have read. Despite its importance, I have had difficulty finding solid info and advice about getting one.  Also, I assume VA Claims Insider probably reads this forum, and I don't want to disparage anyone who is trying to help vets.

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Welcome to Hadit!

I'm glad you know about nexus letters and their purpose. That often is the key factor that causes trouble.

Here are some good links to help you out:

https://www.hadit.com/nexus-letter

-and-

My nexus letters stated:
- Doctor described his curriculum vitae (qualifications)
- Doctor explained how long he has treated me
- The doctor reviewed my service and post-service medical treatment records from (start date) to (end date)
- Details of the examination (i.e. labs, imaging, physical examination, range of motion including where pain begins), basically what you can find in the DBQ's provided by the VA
- Nexus based on strong medical rationale explaining why your disability is related to service
- Just make sure they don't use vague terms like "probably" or "possibly". "As likely as not", "more/most likely", or "due to/caused by" are the best

Most VA doctors will not write a nexus, but I was surprised when I had one do it. They simply wrote one paragraph in my VA progress notes and used the correct jargon. This is rare from what I hear.

You can ask your doctor to fill out a DBQ, but not all will do it. It is pretty much a C&P without the nexus or record review, but they can add a nexus if they want. Some folks have asked their doc if they would do this and then brought back the form on their next visit.

There are a number of non-VA doctors who do IMO's. The first one that comes to mind is Dr. Craig Bash. A lot of veterans used him, but he is not cheap. Also, keep in mind that just because you pay a doctor for an exam, that doesn't mean they will opine in your favor. Definitely ask around first.

If you can get everything tied up, you can submit a fully developed claim. The VA will review and bring you in for a C&P if they need additional exams or imaging.

If you cannot get everything tied up, consider filing a claim to preserve your effective date. This is when you tell the VA you want to file for X, Y, and Z, but am still putting things together. You have a year to get it submitted otherwise the VA will just deny the issues. You could always reapply at any time.

 

It took me quite a while to go through all of my service treatment, VA, and non-VA medical records. I made a list of every diagnosis and dates. I also obtained a copy of my VA claims file (took months) because it contained some additional information that was not present in the preceding records. This process took quite a while. I researched the VA rating criteria for each potential disability. Get very familiar with this, especially when your decision letter arrives.

 

For cervical, the most common ratings are based on limited range of motion. Keep in mind that maximum range of motion and when pain begins are two completely different things. The VA is supposed to rate on the latter, but doesn't always do it. They are also supposed to use a special protractor (goinometer) to measure the range of motion, but some just eyeball it (could be grounds for a new exam if they deny).

Allergic rhinitis ratings are based on blockage and potential presence of polyps. 

Sleep apnea has criteria based on hypersomolnence (daytime sleepiness) or the use of a CPAP machine. Just make sure you are compliant in using the machine. 

The crazy thing is that the VA considers sleep apnea a respiratory condition in most cases. If you happen to get SC for SA and the rhinitis, the VA might consider it pyramiding and grant the higher of the two ratings for percentage calculation purposes.

I hope this helps. You are doing the right thing by asking questions.

 

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Thanks for the reply Vync. I have already submitted an intent to file in order to preserve the date. Since then I have been gathering my records and reviewing them to make sure it is even appropriate for me to file a claim. Since doing so, I started wondering why the VSO I had used the first time had not submitted for these already. I didn't file a claim when I got off of active orders, because I was still in the reserves and didn't think I could (which I now know is wrong). I also didn't want to get kicked out of the reserves for medical reasons, so I waited until my enlistment was up to file.

I do remember him saying that it would be easier to file for what I did, since I had LOD's in my file already, but I have continuity of symptoms for other conditions that arose in service and still bother me now that I think should have been filed for but were not. Now, 15 years later, I fear it will be harder to service connect, despite 15 years of VA medical records dealing with the same issues. 

I plan on connecting the dots in my claim as much as I can. I have a spreadsheet of all of the issues I am submitting, with date, provider location, and a summary of the visit/lab/test report. I also have a summary for each condition, including the symptoms I experience, and a timeline of Dr visits from the first onset until present. My wife will write a buddy letter as well. I do not keep in touch with anyone I was in the service with, and feel awkward trying to call out of the blue and ask for a letter about something they may not remember (I don't remember that they snored, why would they remember that I did). Which leaves the nexus letter firming up the connection between my medical history, my current diagnosis, and my military service.  I can't think of anything else I can do to make this as strong as possible, but that nexus letter seems to be the vital link.

I have read about Dr Bash on this forum. I have also started finding other "services" like vets4valor and va claims insider, but its hard to find reviews of those services. I would hire an attorney, but I know that is not allowed unless I have been denied already, which is what I am trying to avoid. This is becoming a part time job!

 

 

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Remember that VSO's are human too. There are good ones who are very thorough and some which are not as good to varying degrees. When I got out of the service in 1995, my VSO submitted a single sentence for the disability claim and said I could trust the VA to be thorough. Found out that was completely incorrect and I spent years on appeal.

Keep in mind that you can file secondary disability claims for side effects of medications used to treat your existing SC disabilities. If you have no SC disabilities, you can file against the initial claimed disabilities (pending SC).

It does take a considerable amount of effort, but it sounds like you are on the right track.

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19 hours ago, NoZZZ's said:

Thanks for the reply Vync. I have already submitted an intent to file in order to preserve the date. Since then I have been gathering my records and reviewing them to make sure it is even appropriate for me to file a claim. Since doing so, I started wondering why the VSO I had used the first time had not submitted for these already. I didn't file a claim when I got off of active orders, because I was still in the reserves and didn't think I could (which I now know is wrong). I also didn't want to get kicked out of the reserves for medical reasons, so I waited until my enlistment was up to file.

I do remember him saying that it would be easier to file for what I did, since I had LOD's in my file already, but I have continuity of symptoms for other conditions that arose in service and still bother me now that I think should have been filed for but were not. Now, 15 years later, I fear it will be harder to service connect, despite 15 years of VA medical records dealing with the same issues. 

I plan on connecting the dots in my claim as much as I can. I have a spreadsheet of all of the issues I am submitting, with date, provider location, and a summary of the visit/lab/test report. I also have a summary for each condition, including the symptoms I experience, and a timeline of Dr visits from the first onset until present. My wife will write a buddy letter as well. I do not keep in touch with anyone I was in the service with, and feel awkward trying to call out of the blue and ask for a letter about something they may not remember (I don't remember that they snored, why would they remember that I did). Which leaves the nexus letter firming up the connection between my medical history, my current diagnosis, and my military service.  I can't think of anything else I can do to make this as strong as possible, but that nexus letter seems to be the vital link.

I have read about Dr Bash on this forum. I have also started finding other "services" like vets4valor and va claims insider, but its hard to find reviews of those services. I would hire an attorney, but I know that is not allowed unless I have been denied already, which is what I am trying to avoid. This is becoming a part time job!

 

 

Unless, you were diagnosed in-service with sleep apnea. It will be difficult to "direct-service" connect. But, if you know that you went to medical and it's documented you complained of sleep problems such as; waking up gasping for air, choking, severe daytime sleepiness,sleep study confirming sleep apnea in-service, cpap issued in-service etc.You may have a case for direct-service connection.

Since you've been out of the service for awhile, the best route to take is "secondary connection". If you have a service-connected mental health, heart, respiratory,diabetes, neurological condition(TBI or other brain condition) Sleep Apnea is linked to those type of conditions.

Here is what is required to secondary service connect:

1.Must have a service connected disability.

2. Current diagnosis of disability claimed

3. Dr.Nexus of opinion stating "at least as likely as not" #1 and #2 are linked plus a rationale.

I  claimed OSA as secondary to ptsd. I was granted OSA ten yrs after service.

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Thanks for the replies.

I do think that I will have to rely on secondary connection, but I am going to propose direct anyway, since this all started when I was in. I wish I knew more about this process when I had gotten out, but there is nothing I can do about that now.

When I submit my claim, I plan to also submit supporting documentation from medical journals regarding the etiology of the conditions I am experiencing, as a way to reduce a negative C&P argument, particularly related to the time since I have been off of active duty. Do the VA raters even look at stuff like this? Is it considered lay evidence, or does it have more weight since they are scholarly journals?

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