Primary Physician for Sleep Apnea C&P

[JaeNobe]

Hello All, 

I recently submitted a claim for Sleep Apnea secondary to depressive disorder on Friday (1/25). Along with submitting the claim I submitted and IMO from a non-VA doctor.  Today Tuesday 1/29 got a call to schedule my C&P. (World Record to me) Was wondering if anyone else thought this was weird and they also said that my C&P exam was going to be conducted with a Primary Physician not a Sleep Specialist.  I also just thought about it. I didn't submit a DBQ with my initial claim. Could this be the reason? Just seemed off I'm not going to a specialist.

Edited January 29, 2019 by JaeNobe

[doc25]

1 hour ago, JaeNobe said:

The C&P doctor finally updated the the DBQ. Please tell me what you think... 

NOTE: I have submitted to ebenefits a favorable IMO along with studies to prove my secondary condition. 

PULMONARY C & P EXAMINATION CONSULT : 
LOCAL TITLE: C&P RESPIRATORY 
STANDARD TITLE: PULMONARY C & P EXAMINATION CONSULT 
DATE OF NOTE: FEB 12, 2019@12:30 ENTRY DATE: FEB 15, 2019@12:51:05 
AUTHOR: xxxxxxxxxxx-AOUI EXP COSIGNER: 
URGENCY: STATUS: COMPLETED 


Sleep Apnea
Disability Benefits Questionnaire

Name of patient/Veteran: 

Is this DBQ being completed in conjunction with a VA 21-2507, 
C&P Examination
Request?
[X] Yes [ ] No


ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete 
this document:

[X] In-person examination


Evidence Review
---------------
Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS

A . Diagnosis
------------
Does the Veteran have or has he/she ever had sleep apnea?
[X] Yes [ ] No

[X] Obstructive
ICD code: G47.33 Date of diagnosis: 2006

2. Medical history
------------------
a. Describe the history (including onset and course) of the 
Veteran's sleep
disorder condition (brief summary):
3/5/02
STR - YES TO FREQUENT TROUBLE SLEEPING - AND DEPRESSION 
SINCE ONSET OF
?CHAPTER PROCEDURE ENTERING ALCOHOL COUNSELLING FOR 
INCREASED ETOH USE
(???)

2/7/02
HEIGHT: 5'11
WEIGHT: 195 LBS
BMI = 27.2

BMI AT TIME OF OSA DIAGNOSIS = 32

b. Is continuous medication required for control of a sleep 
disorder
condition?
[ ] Yes [X] No

c. Does the Veteran require the use of a breathing assistance 
device?
[ ] Yes [X] No

d. Does the Veteran require the use of a continuous positive 
airway pressure
(CPAP) machine?
[X] Yes [ ] No

3. Findings, signs and symptoms
-------------------------------
Does the Veteran currently have any findings, signs or symptoms 
attributable
to sleep apnea?
[ ] Yes [X] No


4. Other pertinent physical findings, complications, conditions, 
signs,
symptoms and scars
----------------------------------------------------------------
-------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any 
conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) 
related to any
conditions or to the treatment of any conditions listed in 
the Diagnosis
Section above?
[ ] Yes [X] No

c. Comments, if any:
No response provided.

5. Diagnostic testing
---------------------
a. Has a sleep study been performed?
[X] Yes [ ] No

If yes, does the Veteran have documented sleep disorder 
breathing?
[X] Yes [ ] No

Date of sleep study: 7/25/06

Facility where sleep study performed, if known: HOUSTON 
VA

Results:
AHI = 19
RDI = 25
SAO2 NADIR = 76%

b. Are there any other significant diagnostic test findings 
and/or results?
[ ] Yes [X] No


6. Functional impact
--------------------
Does the Veteran's sleep apnea impact his or her ability to 
work?
[ ] Yes [X] No


7. Remarks, if any:
-------------------
FULL TIME EMPLOYED DOING INVENTORY FOR COMPUTER HARDWARE X 3 
YEARS



****************************************************************************


Medical Opinion
Disability Benefits Questionnaire

Name of patient/Veteran: NOBLE, JAMES LAVONN

ACE and Evidence Review
-----------------------
Indicate method used to obtain medical information to complete 
this document:

[X] In-person examination


Evidence Review
---------------
Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS


MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION: 

a. Opinion from general remarks:
**CLAIM TYPE: ORIGINAL
**SPECIAL CONSIDERATIONS: FDC
**INSUFFICIENT EXAM: NO

ELECTRONIC CLAIMS FOLDER AVAILABLE.
JAMES NOBLE
088-64-9350

The Veteran has filed a fully developed claim. 
Please expedite.

Date of claim: 01/25/2019

Days pending: 4

Veteran has a power of attorney.

Please send a courtesy copy of the exam notice 
letter to 049 - TEXAS 
VETERANS COMMISSION

Attention C&P clinical staff - This exam request was 
scheduled at your 
location based on the claimant's residing zip code 
and ERRA instructions.
These remarks were generated using version 4.45 of 
the Exam Request Builder 
(ERB_v_4.45).

The Veteran will need to report for the following exam(s) 
unless the ACE process is utilized. Clinician: If using 
the ACE process to complete the DBQ, please explain the 
basis for the decision not to examine the Veteran, 
and identify the specific materials reviewed to complete 
he DBQ. Also if the exam is completed using ACE, please 
review the Veteran's claims folder 
and indicate so in the exam report.

DBQ RESP Sleep apnea
_________________________________________________________


The following contentions need to be examined:

Sleep Apnea secondary to Depressive Disorder
Medical Opinion 

Active duty service dates:

Branch: Army

EOD: 08/17/1999
RAD: 06/28/2002



DBQ RESP Sleep apnea:

Please review the Veteran's electronic folder in 
VBMS and state that it was 
reviewed in your report.

A sleep study is already of record in the Veteran's 
claims folder.

MEDICAL OPINION REQUEST

TYPE OF MEDICAL OPINION REQUESTED: 
Secondary Service connection.

OPINION REQUESTED: Secondary Service Connection.

Is the Veteran's Sleep Apnea secondary to 
Depressive Disorder at least as 
likely as not (50 percent or greater probability) 
proximately due to or the 
result of depressive disorder (claimed as depression)?

Rationale must be provided in the appropriate section. 
Your review is not 
limited to the evidence identified on this request form, 
or tabbed in the 
claims folder. If an examination or additional testing 
is required, obtain 
them prior to rendering your opinion.

POTENTIALLY RELEVANT EVIDENCE:

NOTE: Your (examiner) review of the record is 
NOT restricted to the 
evidence listed below. This list is provided 
in an effort to assist the 
examiner in locating potentially relevant evidence.

Tab A (Private treatment record in VBMS): 
Independent medical expert opinion 
dated 01/21/2019

Please direct any questions regarding this request to:

Diane Martinez
477 Michigan Av
Detroit, MI 48226
Phone number: (313)471-3936 Ext 2152
Email: diane.martinez@va.gov




b. Indicate type of exam for which opinion has 
been requested: SLEEP APNEA

*** REFERENCED DOCUMENTATION WERE REVIEWED ***


TYPE OF MEDICAL OPINION PROVIDED: 
[ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ]

b. The condition claimed is less likely than not 
(less than 50% probability) proximately due to or the 
result of the Veteran's service connected condition. 

c. Rationale: 
OBSTRUCTIVE SLEEP APNEA IS A PHYSIOLOGICAL CONDITION 
OF THE UPPER AIRWAYS. ALTHOUGH SLEEP DISTURBANCE IS A 
SYMPTOM OF MOOD DISORDER, IT WOULD NOT CAUSE THE 
SOFT-PALATE PROBLEM ASSOCIATED
WITH SLEEP APNEA. 

"SLEEP APNEA IS A PERIODIC COMPLETE (CAUSING APNEA) OR 
PARTIAL (CAUSING HYPOPNEA) COLLAPSE OF PHARYNGEAL SOFT 
TISSUE DURING SLEEP"
http://www.dynamed.com/topics/dmp~AN~T115600/Obstructive-sleep-
apnea-OSA-in-a
dults#General-Information


IT IS NOTED THAT THE VETERAN'S BMI HAD INCREASED FROM 27 TO 32 
(AT
THE TIME OF DIAGNOSIS; BMI OF 30 AND ABOVE IS CATEGORIZED AS 
OBESE.

OBESITY IS ONE OF THE STRONGEST RISK FACTOR FORSLEEP APNEA. 
IT IS ASSOCIATED WITH ALTERATIONS OF ANATOMY THAT MAY LEAD TO 
UPPER AIRWAY OBSTRUCTION BY INCREASING THE NECK CIRCUMFERENCE 
AND DEPOSITS OF FAT AROUND THE NECK. THIS PLACES A LOAD ON THE 
UPPER AIRWAY THAT MAY LEAD TO AIRFLOW OBSTRUCTION. 
http://www.atsjournals.org/doi/full/10.1513/pats.200708-
137MG#_i1


OTH REFERENCES:
1) http://www.uptodate.com/contents/overview-of-obstructive-
sleep-
apnea-in-adult
s?source=search_result&search=SLEEP+APNEA&selectedTitle=1%
7E150
#H760186

2) http://emedicine.medscape.com/article/295807-overview#a4


****************************************************************
*********


xxxxxxx
PA-C, MMSc
Signed: 02/15/2019 12:51

Just as I suspected would happen. A doggone PA-C did your exam and gave you an unfavorable nexus of opinion vs a favorable nexus of opinion. Looks like a tie to me.

https://www.hillandponton.com/va-benefit-of-the-doubt/

Don't be surprised if it gets denied. My secondary Sleep Apnea was denied twice. 

Can you post Dr. Anaise IMO, if you haven't already? Redact any personal identifying information.

[doc25]

This article cites the article I provided in an earlier post.

Reference #9  and it is mentioned in the DISCUSSION.

Sleep apnea, psychopathology, and mental health care.pdf

That PA-C doesn't know what he/she is talking about. 

[JaeNobe]

12 hours ago, doc25 said:

Just as I suspected would happen. A doggone PA-C did your exam and gave you an unfavorable nexus of opinion vs a favorable nexus of opinion. Looks like a tie to me.

https://www.hillandponton.com/va-benefit-of-the-doubt/

Don't be surprised if it gets denied. My secondary Sleep Apnea was denied twice. 

Can you post Dr. Anaise IMO, if you haven't already? Redact any personal identifying information.

Its about 19 pages long but i tried to shorten it

 

As my attached curriculum vitae indicates [Exhibit 1], I am a surgeon with almost thirty years of medical experience. I was Clinical Associate Professor of Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook. I served as President of the New York

'·'

Transplantation Society and as Assistant Editor of Transplantation Proceedings. I hold three patents. I have authored three book chapters and 106 research papers published in peer reviewed medical journals.

Opinions

The following opinions are all to a reasonable degree of medical certainty at least at the "more likely than not" (more than 50 percent) level.

I do not have a vested interest in the assignment of this patient's medical diagnostic codes as I am an expert and paid a flat fee prior to the writing of any of my reports. My opinions are based on the judicious application of the medical principles / my training / experience.

This report conforms to the federal guidelines on expert testimony as they apply to medical data/facts, reliable principles/methods (see my attached C.V. and book references), and the application of medical principles/methods to the facts/data and is therefore not in any way speculative.

 

After reviewing the veteran's c-file and the pertinent recent medical literature, I opine that it is more likely than not that the veteran's sleep apnea is caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries.

Sleep apnea diagnosis

 

A sleep medicine consult dated July 20, 2006 reports [Exhibit 2]:

"The supervising practitioner of record for this patient care encounter is Dr. Sharafkhaneh, Amir.

HISTORY OF PRESENTING ILLNESS

Patient is a 26 y/o veteran who is being evaluated in sleep clinic for excessive day time sleepiness. He typically retires at about 10 pm .Falls asleep in about 20 mins. He does not c/o restless leg activity while going to sleep. His sleep is not interrupted by nocturnal awakenings. He wakes up at 4:30 am. On awakening patient feels /does not feel refreshed. He has a dry mouth but no head ache on waking up. He has nocturnal reflux episodes. He does not report any symptoms s/o narcolepsy of cataplexy, hypogogic hallucinations or on rare occasions he has experienced sleep paralysis. He does not report any parasornnias.

Epworth Sleepiness scale 10

Depression Score ...

Assessment:

Patient appears to have Obstructive Sleep Apnea with an Epworth Score of 10 indicating mild excessive day time sleepiness."

 

A medical record dated February 23, 2007 shows [Exhibit 3]:

"The supervising practitioner of record for this patient care encounter is

Dr. Sharafkhaneh, Amir.

Referred for: Patient is a 26 year old veteran referred with Obstructive sleep

apnea who is seen for follow up. CPAP machine is set at a pressure of 8 H20 .Checked against a manometer and delivers the set pressure."

 

There are two basic mechanisms for obstructive sleep apnea. The first is static narrowing of the airways due to swelling of structures that block the airway. Some examples are septal deviation of the nose, or accumulation of fat in the retro pharynx noted in certain types of obesity. The second, and more frequent reason for sleep apnea, are dynamic processes that involve the muscle tone, mostly of the tongue due to hypotonia of the genioglossus muscle.

Jordan et al.i published a study: Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea:

 

"Obstructive sleep apnea (OSA) is a common disorder, characterized by repetitive upper airway collapse during sleep. Upper airway collapse in OSA is thought to occur at sleep onset because of the reduction of activity of several upper airway dilator muscles, which then do not hold the anatomically vulnerable airway open.

The severity of OSA varies throughout the night and between sleep stages. Generally, obstructive respiratory events are more common and longer in REM than NREM sleep."

 

airway. Jordan et al. have shown that when patients with OSA spontaneously overcome their

tendency for airway collapse and have stable breathing during sleep, the genioglossus muscle is

more active than during disordered breathing events:

 

"Electrical activation of the genioglossus muscle or hypoglossal nerve is known to dilate the retroglossal airway and reduce the pharyngeal critical closing pressure in humans. Thus, it would appear lik􀀉.ly that the increased genioglossus muscle activity is playing a causal role in contributing to the sleep stage and time of night differences in the severity ofOSA ...

Prior research has shown that the genioglossus is activated by chemoreceptor stimulation and by reflex activation in response to negative pressure. There is also evidence to suggest that the genioglossus receives an independent stimulation during wakefulness which is lost at sleep onset and is known as the 'wakefulness stimulus'."

 

Sleep apnea secondary to Veteran's service-connected mood disorder

It is my professional opinion that Veteran's sleep apnea is more likely than not caused by and/or aggravated by his service-connected psychiatric condition (depressive disorder). Sleep apnea in military personnel has now reached an epidemic proportion. A studyii from the Defense Medical Surveillance System (DMSS) reported the incidence of OSA and associated attrition from service in active component military members from 1 January 2004 through 31 May 2016. The study identified 223,731 incident cases of OSA with an overall incidence rate of 13 9 .2 per 10,000 person-years, between 2004 and 2015. Rates increased more than 3-fold between 2004 and 2015. In 2015, 48.1 % of all incident cases of OSA were diagnosed in the last year of service.

Sharafkhanel et al. in the study Association of psychiatric disorders and sleep apnea in a large cohort iii' reviewed the Veterans Health Administration data from 1998 to 2001 and identified patient records indicating sleep apnea and various psychiatric conditions. Out of 4,060,504 unique cases, 118,105 were identified as having sleep apnea ( estimated prevalence of 2.91 % ). Psychiatric comorbid diagnoses in the sleep apnea group included depression (21.8% ), anxiety (16. 7% ), posttraumatic stress disorder (11. 9% ), psychosis (5 .1 % ), and bipolar disorders (3.3%). Compared with patients not diagnosed with sleep apnea, a significantly greater prevalence (P < .0001) was fou)!d for mood disorders, anxiety, posttraumatic stress disorder, psychosis, and dementia in patients with sleep apnea. The study concluded that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries.

Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel.iv Mysliwiec et alv studied the associations between sleep disorders and service-related diagnoses of depression and posttraumatic stress disorder (PTSD). They evaluated 110 active duty soldiers referred to the sleep disorders clinic within 18 months of deployment. These soldiers were young ( average age 33.6 years) and not obese. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. 38.2% had comorbid insomnia and OSA. The incidence of PTSD, TBI and mood disorder reached

 

Conclusion

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 caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries. While each of these conditions solely is sufficient to cause OSA, clearly a combination of these disabilities will cause OSA.

[doc25]

7 hours ago, JaeNobe said:

Its about 19 pages long but i tried to shorten it

 

As my attached curriculum vitae indicates [Exhibit 1], I am a surgeon with almost thirty years of medical experience. I was Clinical Associate Professor of Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook. I served as President of the New York

'·'

Transplantation Society and as Assistant Editor of Transplantation Proceedings. I hold three patents. I have authored three book chapters and 106 research papers published in peer reviewed medical journals.

Opinions

The following opinions are all to a reasonable degree of medical certainty at least at the "more likely than not" (more than 50 percent) level.

I do not have a vested interest in the assignment of this patient's medical diagnostic codes as I am an expert and paid a flat fee prior to the writing of any of my reports. My opinions are based on the judicious application of the medical principles / my training / experience.

This report conforms to the federal guidelines on expert testimony as they apply to medical data/facts, reliable principles/methods (see my attached C.V. and book references), and the application of medical principles/methods to the facts/data and is therefore not in any way speculative.

 

After reviewing the veteran's c-file and the pertinent recent medical literature, I opine that it is more likely than not that the veteran's sleep apnea is caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries.

Sleep apnea diagnosis

 

A sleep medicine consult dated July 20, 2006 reports [Exhibit 2]:

"The supervising practitioner of record for this patient care encounter is Dr. Sharafkhaneh, Amir.

HISTORY OF PRESENTING ILLNESS

Patient is a 26 y/o veteran who is being evaluated in sleep clinic for excessive day time sleepiness. He typically retires at about 10 pm .Falls asleep in about 20 mins. He does not c/o restless leg activity while going to sleep. His sleep is not interrupted by nocturnal awakenings. He wakes up at 4:30 am. On awakening patient feels /does not feel refreshed. He has a dry mouth but no head ache on waking up. He has nocturnal reflux episodes. He does not report any symptoms s/o narcolepsy of cataplexy, hypogogic hallucinations or on rare occasions he has experienced sleep paralysis. He does not report any parasornnias.

Epworth Sleepiness scale 10

Depression Score ...

Assessment:

Patient appears to have Obstructive Sleep Apnea with an Epworth Score of 10 indicating mild excessive day time sleepiness."

 

A medical record dated February 23, 2007 shows [Exhibit 3]:

"The supervising practitioner of record for this patient care encounter is

Dr. Sharafkhaneh, Amir.

Referred for: Patient is a 26 year old veteran referred with Obstructive sleep

apnea who is seen for follow up. CPAP machine is set at a pressure of 8 H20 .Checked against a manometer and delivers the set pressure."

 

There are two basic mechanisms for obstructive sleep apnea. The first is static narrowing of the airways due to swelling of structures that block the airway. Some examples are septal deviation of the nose, or accumulation of fat in the retro pharynx noted in certain types of obesity. The second, and more frequent reason for sleep apnea, are dynamic processes that involve the muscle tone, mostly of the tongue due to hypotonia of the genioglossus muscle.

Jordan et al.i published a study: Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea:

 

"Obstructive sleep apnea (OSA) is a common disorder, characterized by repetitive upper airway collapse during sleep. Upper airway collapse in OSA is thought to occur at sleep onset because of the reduction of activity of several upper airway dilator muscles, which then do not hold the anatomically vulnerable airway open.

The severity of OSA varies throughout the night and between sleep stages. Generally, obstructive respiratory events are more common and longer in REM than NREM sleep."

 

airway. Jordan et al. have shown that when patients with OSA spontaneously overcome their

tendency for airway collapse and have stable breathing during sleep, the genioglossus muscle is

more active than during disordered breathing events:

 

"Electrical activation of the genioglossus muscle or hypoglossal nerve is known to dilate the retroglossal airway and reduce the pharyngeal critical closing pressure in humans. Thus, it would appear lik􀀉.ly that the increased genioglossus muscle activity is playing a causal role in contributing to the sleep stage and time of night differences in the severity ofOSA ...

Prior research has shown that the genioglossus is activated by chemoreceptor stimulation and by reflex activation in response to negative pressure. There is also evidence to suggest that the genioglossus receives an independent stimulation during wakefulness which is lost at sleep onset and is known as the 'wakefulness stimulus'."

 

Sleep apnea secondary to Veteran's service-connected mood disorder

It is my professional opinion that Veteran's sleep apnea is more likely than not caused by and/or aggravated by his service-connected psychiatric condition (depressive disorder). Sleep apnea in military personnel has now reached an epidemic proportion. A studyii from the Defense Medical Surveillance System (DMSS) reported the incidence of OSA and associated attrition from service in active component military members from 1 January 2004 through 31 May 2016. The study identified 223,731 incident cases of OSA with an overall incidence rate of 13 9 .2 per 10,000 person-years, between 2004 and 2015. Rates increased more than 3-fold between 2004 and 2015. In 2015, 48.1 % of all incident cases of OSA were diagnosed in the last year of service.

Sharafkhanel et al. in the study Association of psychiatric disorders and sleep apnea in a large cohort iii' reviewed the Veterans Health Administration data from 1998 to 2001 and identified patient records indicating sleep apnea and various psychiatric conditions. Out of 4,060,504 unique cases, 118,105 were identified as having sleep apnea ( estimated prevalence of 2.91 % ). Psychiatric comorbid diagnoses in the sleep apnea group included depression (21.8% ), anxiety (16. 7% ), posttraumatic stress disorder (11. 9% ), psychosis (5 .1 % ), and bipolar disorders (3.3%). Compared with patients not diagnosed with sleep apnea, a significantly greater prevalence (P < .0001) was fou)!d for mood disorders, anxiety, posttraumatic stress disorder, psychosis, and dementia in patients with sleep apnea. The study concluded that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries.

Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel.iv Mysliwiec et alv studied the associations between sleep disorders and service-related diagnoses of depression and posttraumatic stress disorder (PTSD). They evaluated 110 active duty soldiers referred to the sleep disorders clinic within 18 months of deployment. These soldiers were young ( average age 33.6 years) and not obese. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. 38.2% had comorbid insomnia and OSA. The incidence of PTSD, TBI and mood disorder reached

 

Conclusion

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 caused by and/or aggravated by his service-connected conditions of depressive disorder and chronic pain syndrome related to his service-connected injuries. While each of these conditions solely is sufficient to cause OSA, clearly a combination of these disabilities will cause OSA.

Hell yea.

Notice the difference between the unfavorable nexus vs the favorable nexus?

[JaeNobe]

3 hours ago, doc25 said:

Hell yea.

Notice the difference between the unfavorable nexus vs the favorable nexus?

Huge difference... I just hope the RO sees it in my favor.

[dajoker12]

There is a lot of research out there that shows a strong correlation btweeen sleep apnea and: depression, anxiety, ptsd and especially schizophrenia. 

Submitting a DBQ would have helped with a medical opinion.  I have seen it get service connected secondary to ptsd a plurality of times when it was accompanied with a strong rationale. 

I did not have mine diagnosed while in service. I obtained six buddy statements verifying the symptoms. A dbq and medical opinion from a sleep specialist for a direct service connection. A medical opinion from a psychologist saying that it could equality be direct service connection or secondary to ptsd and that they aggravate one another. 

No exam necessary. I was service connected for every single contention that I put in for.