timeline

[Chrys86]

Hey Guys

 

I know this is probably asked like a million times over and over again but anyone know how long initial claims are taking to process? Im kind of going stir crazy. I filed December 10th 2018, I had my C&P exams on Jan. 18th. On Feb 21st they closed a request for information stating "No longer needed" (What does that even mean) And I have been sitting at gathering evidence ever since.

 

I read over my exams and everything seems favorable so I know a rating is coming, just wondering when I could see the next step happening.  

[Chrys86]

32 minutes ago, Buck52 said:

What are you filing for?

can you put a redacted copy of your C&P Exam on here? cover /black out your name and claim #

Members can better help you if they see your C&P Report And what your filing for?

Here is exam. I took out some stuff that had where I worked etc so it may look like letters are missing. 

 

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

 

ICD code: 000

 

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 000

 

b. Medical diagnoses relevant to the understanding or management of the

mental health disorder (to include TBI): Meniers disease, Migraine

headaches.

ICD code: 000

 

3. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

 

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [X] No [ ] Not shown in records reviewed

 

4. Occupational and social impairment

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

a. Which of the following best summarizes the Veteran's level of occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with deficiencies in most areas,

such as work, school, family relations, judgment, thinking and/or mood

b. For the indicated occupational and social impairment, is it possible to

differentiate which impairment is caused by each mental disorder?

[ ] Yes [ ] No [X] Not Applicable (N/A)

 

c. If a diagnosis of TBI exists, is it possible to differentiate which

occupational and social impairment indicated above is caused by the TBI?

[ ] Yes [ ] No [X] Not Applicable (N/A)

 

SECTION II:

-----------

Clinical Findings:

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

1. Evidence Review

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

Evidence reviewed (check all that apply):

 

[X] VA e-folder

[X] CPRS

 

 

c. Relevant mental health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

2019 Post-Traumatic Stress Disorder, Chronic (ICD-10-CM F43.12)

The Veteran denies mental problems pre military.Veteran denies family

history of mental illness.

 

The Veteran's symptoms of anxiety, irritability and isolation began

while in the Coast Guard for interdicting Illegals from Cuba and drug

smuglers in Soyh America waters.

 

The Veteran denies suicide attempts in past.

 

The Veteran's most recent VAMHC appointment was on 1/1/2019 with

diagnosis of Post-Traumatic Stress Disorder, Chronic (ICD-10-CM

F43.12). The Veteran is presently on the following psychotropic

medication: 

 

 

d. Relevant legal and behavioral history (pre-military, military, and

post-military):

DUI x1 in 2017.

 

e. Relevant substance abuse history (pre-military, military, and

post-military):

 

The Veteran denies alcohol usage.

The Veteran denies illegal drugs.

The Veteran denies any alcohol or drug treatment.She has attended a few

AA meetings in 2017.

 

f. Other, if any:

No response provided.

 

3. Stressors

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

Describe one or more specific stressor event(s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

 

a. Stressor #1: In Coast Guard Duty she saw dismemberment while catching a

drug smuggler.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

Was on activity duty on board a ship but not in a combat zone.

 

b. Stressor #2: She saw migrants who were caught being chained and she felt

poorly treated for the few months many of them had to stay on the

ship.She is Cuban descent and was horrified at their alleged

treatment.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

She felt horrified at their treatment.She blames herself for not

speaking up about what she saw.This covered a 2 year period.

 

c. Stressor #3: She felt threatened a great deal of the time on ship based on

the dangerous Drug Smugglers they caught.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

She helped catch 60 smugglers over the 2 year period.

 

4. PTSD Diagnostic Criteria

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

Note: Please check criteria used for establishing the current PTSD diagnosis.

Do NOT mark symptoms below that are clearly not attributable to the Criterion

A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other

things should be noted under #7 - Other symptoms. The diagnostic criteria

for PTSD, referred to as Criterion A-H, are from the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DSM-5).

 

Criterion A: Exposure to actual or threatened a) death, b) serious injury,

c) sexual violence, in one or more of the following ways:

 

[X] Directly experiencing the traumatic event(s)

[X] Witnessing, in person, the traumatic event(s) as they

occurred to others

 

Criterion B: Presence of (one or more) of the following intrusion symptoms

associated with the traumatic event(s), beginning after the

traumatic event(s) occurred:

 

[X] Recurrent, involuntary, and intrusive distressing memories

of the traumatic event(s).

[X] Recurrent distressing dreams in which the content and/or

affect of the dream are related to the traumatic event(s).

[X] Dissociative reactions (e.g., flashbacks) in which the

individual feels or acts as if the traumatic event(s) were

recurring. (Such reactions may occur on a continuum, with

the most extreme expression being a complete loss of

awareness of present surroundings).

[X] Intense or prolonged psychological distress at exposure to

internal or external cues that symbolize or resemble an

aspect of the traumatic event(s).

[X] Marked physiological reactions to internal or external

cues that symbolize or resemble an aspect of the traumatic

event(s).

 

Criterion Persistent avoidance of stimuli associated with the traumatic

event(s), beginning after the traumatic events(s) occurred,

as evidenced by one or both of the following:

 

[X] Avoidance of or efforts to avoid distressing memories,

thoughts, or feelings about or closely associated with the

traumatic event(s).

[X] Avoidance of or efforts to avoid external reminders

(people, places, conversations, activities, objects,

situations) that arouse distressing memories, thoughts, or

feelings about or closely associated with the traumatic

event(s).

 

Criterion Negative alterations in cognitions and mood associated with

the traumatic event(s), beginning or worsening after the

traumatic event(s) occurred, as evidenced by two (or more) of

the following:

 

[X] Persistent and exaggerated negative beliefs or

expectations about oneself, others, or the world (e.g., "I

am bad,: "No one can be trusted,: "The world is completely

dangerous,: "My whole nervous system is permanently

ruined").

[X] Persistent, distorted cognitions about the cause or

consequences of the traumatic event(s) that lead the

individual to blame himself/herself or others.

[X] Persistent negative emotional state (e.g., fear, horror,

anger, guilt, or shame).

[X] Markedly diminished interest or participation in

significant activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions

(e.g., inability to experience happiness, satisfaction, or

loving feelings.)

 

Criterion E: Marked alterations in arousal and reactivity associated with

the traumatic event(s), beginning or worsening after the

traumatic event(s) occurred, as evidenced by two (or more) of

the following:

 

[X] Irritable behavior and angry outbursts (with little or no

provocation) typically expressed as verbal or physical

aggression toward people or objects.

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying

asleep or restless sleep).

 

Criterion F:

 

[X] Duration of the disturbance (Criteria B, C, D, and E) is

more than 1 month.

 

Criterion G:

 

[X] The disturbance causes clinically significant distress or

impairment in social, occupational, or other important

areas of functioning.

 

Criterion H:

No response provided.

 

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

 

[X] Stressor #1

[X] Stressor #2

 

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

 

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks that occur weekly or less often

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent

events

[X] Flattened affect

[X] Difficulty in understanding complex commands

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or a

worklike setting

[X] Inability to establish and maintain effective relationships

[X] Obsessional rituals which interfere with routine activities

[X] Neglect of personal appearance and hygiene

[X] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

 

6. Behavioral Observations

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

Mental Status Evaluation today.

The Veteran was awake and alert.She was tremulous.

General appearance is within normal limits.

Veteran showed no unusual gestures or grimaces.

Affect was flat.

The veteran is oriented in all 3 spheres.

General information is within normal limits.

Recent and remote memory are intact.

Judgement within normal limits.

Number sense is within normal limits including subtracting serial sevens.

Veteran denied auditory and visual hallucinations and/or delusions. 

Veteran denied wanting to harm or kill self or others. The Veteran denied

suicidal or homicidal ideation or intent.

 

7. Other symptoms

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

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[ ] Yes [X] No

 

8. Competency

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

 

9. Remarks, (including any testing results) if any

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

I explained to the veteran that the data I am collecting from the veteran

would be read by others in evaluating the veteran's claim and therefore

the usual confidentiality the Veteran might expect in a visit with a

physician would not apply in this setting. The veteran states that the

veteran understood this and was willing to proceed with the examination. 

The criteria contained in DSM-V are being used for this evaluation. 

I suggested the veteran continue mental health treatment for the veteran's

mental health problems. 

I gave the veteran a paper containing the following telephone numbers: 

National Suicide Hotline Resource:1-800-273-TALK (8255);

Emergency Contact: (when you need immediate help/support); 

Nashville ER: 615-327-4751 or 1-800-876-7093 ext. 67790

Murfreesboro ER: 615-867-6000 ext. 24862

Non Emergent Contact: (when you need non immediate help/support) 

Tennessee Valley Health Care System Telephone Care Nurse

Line: Monday - Friday 8:00 a.m. until 4:30 p.m

1-800-228-4973. After Hours: 1-877-291-5311.

See MO.

 

 

 

 

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

 

 

Medical Opinion

Disability Benefits Questionnaire

 

Name of patient/Veteran: 

 

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: The Veteran filed a claim within a year of

his or her discharge from active 

duty military service. Please evaluate the following disabilities:

 

" ptsd,

 

 

b. Indicate type of exam for which opinion has been requested: Initial PTSD

 

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ] 

 

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event or

illness. 

 

c. Rationale: The claimed stressors are related to the Veteran’s fear of

military activity. The claimed stressors are adequate to support a diagnosis

of PTSD. The Veterans symptoms are related to the claimed stressors.

 

The Veteran has significant symptoms of PTSD which include hyper vigilance,

depression, chronic sleep disturbance, flashbacks, poor concentration,

isolating more and having irritability to other people to the point of

anger. 

[doc25]

11 minutes ago, Chrys86 said:

Ill try and upload my exam for PTSD in a moment as soon as I find it. The gentleman on the phone said they still needed my personal records but yes I submitted everything else for the claim with the help of a VSO. 

 

As far as what i filed for.

PTSD, Migraines, Vertigo, Tinnitus, Syncope, Hearing Loss, right shoulder, hip, knee, ankle injury. 

Should you get PTSD granted...and you have or develop sleep apnea. You can secondary connect Sleep Apnea to PTSD. Other forum members and I can help provide information for that.

FYI, every service-connected disability granted has secondary conditions that can be caused or aggravated by them.

[Chrys86]

Just now, doc25 said:

Should you get PTSD granted...and you have or develop sleep apnea. You can secondary connect Sleep Apnea to PTSD. Other forum members and I can help provide information for that.

FYI, every service-connected disability granted has secondary conditions that can be caused or aggravated by them.

I will definitely be reaching out as I do feel as though I have sleep apnea, when I don't have insomnia and I didn't even think to put it in the claim.  

[doc25]

12 minutes ago, Chrys86 said:

Here is exam. I took out some stuff that had where I worked etc so it may look like letters are missing. 

 

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

 

ICD code: 000

 

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD

ICD code: 000

 

b. Medical diagnoses relevant to the understanding or management of the

mental health disorder (to include TBI): Meniers disease, Migraine

headaches.

ICD code: 000

 

3. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

 

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [X] No [ ] Not shown in records reviewed

 

4. Occupational and social impairment

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

a. Which of the following best summarizes the Veteran's level of occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with deficiencies in most areas,

such as work, school, family relations, judgment, thinking and/or mood

b. For the indicated occupational and social impairment, is it possible to

differentiate which impairment is caused by each mental disorder?

[ ] Yes [ ] No [X] Not Applicable (N/A)

 

c. If a diagnosis of TBI exists, is it possible to differentiate which

occupational and social impairment indicated above is caused by the TBI?

[ ] Yes [ ] No [X] Not Applicable (N/A)

 

SECTION II:

-----------

Clinical Findings:

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

1. Evidence Review

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

Evidence reviewed (check all that apply):

 

[X] VA e-folder

[X] CPRS

 

 

c. Relevant mental health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

2019 Post-Traumatic Stress Disorder, Chronic (ICD-10-CM F43.12)

The Veteran denies mental problems pre military.Veteran denies family

history of mental illness.

 

The Veteran's symptoms of anxiety, irritability and isolation began

while in the Coast Guard for interdicting Illegals from Cuba and drug

smuglers in Soyh America waters.

 

The Veteran denies suicide attempts in past.

 

The Veteran's most recent VAMHC appointment was on 1/1/2019 with

diagnosis of Post-Traumatic Stress Disorder, Chronic (ICD-10-CM

F43.12). The Veteran is presently on the following psychotropic

medication: 

 

 

d. Relevant legal and behavioral history (pre-military, military, and

post-military):

DUI x1 in 2017.

 

e. Relevant substance abuse history (pre-military, military, and

post-military):

 

The Veteran denies alcohol usage.

The Veteran denies illegal drugs.

The Veteran denies any alcohol or drug treatment.She has attended a few

AA meetings in 2017.

 

f. Other, if any:

No response provided.

 

3. Stressors

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

Describe one or more specific stressor event(s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

 

a. Stressor #1: In Coast Guard Duty she saw dismemberment while catching a

drug smuggler.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

Was on activity duty on board a ship but not in a combat zone.

 

b. Stressor #2: She saw migrants who were caught being chained and she felt

poorly treated for the few months many of them had to stay on the

ship.She is Cuban descent and was horrified at their alleged

treatment.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

She felt horrified at their treatment.She blames herself for not

speaking up about what she saw.This covered a 2 year period.

 

c. Stressor #3: She felt threatened a great deal of the time on ship based on

the dangerous Drug Smugglers they caught.

 

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

 

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity?

[ ] Yes [X] No

 

If no, explain:

She helped catch 60 smugglers over the 2 year period.

 

4. PTSD Diagnostic Criteria

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

Note: Please check criteria used for establishing the current PTSD diagnosis.

Do NOT mark symptoms below that are clearly not attributable to the Criterion

A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other

things should be noted under #7 - Other symptoms. The diagnostic criteria

for PTSD, referred to as Criterion A-H, are from the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DSM-5).

 

Criterion A: Exposure to actual or threatened a) death, b) serious injury,

c) sexual violence, in one or more of the following ways:

 

[X] Directly experiencing the traumatic event(s)

[X] Witnessing, in person, the traumatic event(s) as they

occurred to others

 

Criterion B: Presence of (one or more) of the following intrusion symptoms

associated with the traumatic event(s), beginning after the

traumatic event(s) occurred:

 

[X] Recurrent, involuntary, and intrusive distressing memories

of the traumatic event(s).

[X] Recurrent distressing dreams in which the content and/or

affect of the dream are related to the traumatic event(s).

[X] Dissociative reactions (e.g., flashbacks) in which the

individual feels or acts as if the traumatic event(s) were

recurring. (Such reactions may occur on a continuum, with

the most extreme expression being a complete loss of

awareness of present surroundings).

[X] Intense or prolonged psychological distress at exposure to

internal or external cues that symbolize or resemble an

aspect of the traumatic event(s).

[X] Marked physiological reactions to internal or external

cues that symbolize or resemble an aspect of the traumatic

event(s).

 

Criterion Persistent avoidance of stimuli associated with the traumatic

event(s), beginning after the traumatic events(s) occurred,

as evidenced by one or both of the following:

 

[X] Avoidance of or efforts to avoid distressing memories,

thoughts, or feelings about or closely associated with the

traumatic event(s).

[X] Avoidance of or efforts to avoid external reminders

(people, places, conversations, activities, objects,

situations) that arouse distressing memories, thoughts, or

feelings about or closely associated with the traumatic

event(s).

 

Criterion Negative alterations in cognitions and mood associated with

the traumatic event(s), beginning or worsening after the

traumatic event(s) occurred, as evidenced by two (or more) of

the following:

 

[X] Persistent and exaggerated negative beliefs or

expectations about oneself, others, or the world (e.g., "I

am bad,: "No one can be trusted,: "The world is completely

dangerous,: "My whole nervous system is permanently

ruined").

[X] Persistent, distorted cognitions about the cause or

consequences of the traumatic event(s) that lead the

individual to blame himself/herself or others.

[X] Persistent negative emotional state (e.g., fear, horror,

anger, guilt, or shame).

[X] Markedly diminished interest or participation in

significant activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions

(e.g., inability to experience happiness, satisfaction, or

loving feelings.)

 

Criterion E: Marked alterations in arousal and reactivity associated with

the traumatic event(s), beginning or worsening after the

traumatic event(s) occurred, as evidenced by two (or more) of

the following:

 

[X] Irritable behavior and angry outbursts (with little or no

provocation) typically expressed as verbal or physical

aggression toward people or objects.

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying

asleep or restless sleep).

 

Criterion F:

 

[X] Duration of the disturbance (Criteria B, C, D, and E) is

more than 1 month.

 

Criterion G:

 

[X] The disturbance causes clinically significant distress or

impairment in social, occupational, or other important

areas of functioning.

 

Criterion H:

No response provided.

 

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

 

[X] Stressor #1

[X] Stressor #2

 

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

 

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks that occur weekly or less often

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent

events

[X] Flattened affect

[X] Difficulty in understanding complex commands

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or a

worklike setting

[X] Inability to establish and maintain effective relationships

[X] Obsessional rituals which interfere with routine activities

[X] Neglect of personal appearance and hygiene

[X] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

 

6. Behavioral Observations

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

Mental Status Evaluation today.

The Veteran was awake and alert.She was tremulous.

General appearance is within normal limits.

Veteran showed no unusual gestures or grimaces.

Affect was flat.

The veteran is oriented in all 3 spheres.

General information is within normal limits.

Recent and remote memory are intact.

Judgement within normal limits.

Number sense is within normal limits including subtracting serial sevens.

Veteran denied auditory and visual hallucinations and/or delusions. 

Veteran denied wanting to harm or kill self or others. The Veteran denied

suicidal or homicidal ideation or intent.

 

7. Other symptoms

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

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[ ] Yes [X] No

 

8. Competency

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

 

9. Remarks, (including any testing results) if any

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

I explained to the veteran that the data I am collecting from the veteran

would be read by others in evaluating the veteran's claim and therefore

the usual confidentiality the Veteran might expect in a visit with a

physician would not apply in this setting. The veteran states that the

veteran understood this and was willing to proceed with the examination. 

The criteria contained in DSM-V are being used for this evaluation. 

I suggested the veteran continue mental health treatment for the veteran's

mental health problems. 

I gave the veteran a paper containing the following telephone numbers: 

National Suicide Hotline Resource:1-800-273-TALK (8255);

Emergency Contact: (when you need immediate help/support); 

Nashville ER: 615-327-4751 or 1-800-876-7093 ext. 67790

Murfreesboro ER: 615-867-6000 ext. 24862

Non Emergent Contact: (when you need non immediate help/support) 

Tennessee Valley Health Care System Telephone Care Nurse

Line: Monday - Friday 8:00 a.m. until 4:30 p.m

1-800-228-4973. After Hours: 1-877-291-5311.

See MO.

 

 

 

 

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

 

 

Medical Opinion

Disability Benefits Questionnaire

 

Name of patient/Veteran: 

 

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: The Veteran filed a claim within a year of

his or her discharge from active 

duty military service. Please evaluate the following disabilities:

 

" ptsd,

 

 

b. Indicate type of exam for which opinion has been requested: Initial PTSD

 

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ] 

 

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event or

illness. (Favorable Nexus)

 

c. Rationale: The claimed stressors are related to the Veteran’s fear of

military activity. The claimed stressors are adequate to support a diagnosis

of PTSD. The Veterans symptoms are related to the claimed stressors.

 

The Veteran has significant symptoms of PTSD which include hyper vigilance,

depression, chronic sleep disturbance, flashbacks, poor concentration,

isolating more and having irritability to other people to the point of

anger. 

• 70% – “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.”

 

This is what best describes your criteria. Now it's up to the ratings scheduler to get it right.

[doc25]

2 hours ago, Chrys86 said:

I will definitely be reaching out as I do feel as though I have sleep apnea, when I don't have insomnia and I didn't even think to put it in the claim.  

DO NOT claim Sleep Apnea just yet. You may begin an "INTENT TO FILE" after it's confirmed you have Sleep Apnea from a Sleep Study. Insomnia(trouble falling asleep or going back to sleep) is caused by untreated Sleep Apnea, not the other way around; in most cases.

There's a process to it.

Answer these few questions:

#1. Do you stop breathing in your sleep? Yes or No.

#2. Do you wake up gasping to breathe or feel like you are choking in your sleep? Yes or No.

#3. Do you have family, friends, or a significant other tell you you stop breathing while you sleep or snore? Yes or No.

#4. Do you feel exhausted when you wake up and it takes you more than an hour to "feel fully awake"? Yes or No.

#5. Do you have constant daytime sleepiness? Yes or No.

***Women are less likely to have or develop Sleep Apnea than men, but women do develop it. So, it's not that rare.***

To secondary connect sleep apnea:

#1. Get referred to a Sleep Specialist/Pulmonologist to see if you require a sleep study to see if you have sleep apnea or not.

#2. Get a sleep study to confirm you have Sleep Apnea.

#3. The sleep study or the doctor's note MUST STATE, "medically necessary CPAP" or something similar.( If it doesn't say that, the claim will be denied.)

#4. You must meet this criteria:

i) Current Sleep Apnea Diagnosis (You don't have a diagnosis yet)

ii) Have a service-connected disability (PTSD)

iii) Nexus of opinion stating the minimum threshold of "at least as likely as not" the veteran's sleep apnea is due to or the direct result of service connected PTSD. A rationale must be provided linking Sleep Apnea to PTSD. 

 

Edited March 9, 2019 by doc25

[Buck52]

I would say this will be a 70% rating based on the above exam.

As for as sleep apnea, you need to let your MH Dr know you don't sleep good or what ever problem you maybe having, if you stop brething during your sleep   that is not good , you need someone to let you know you snore and you stop breathing and jump to catch your breath   that someone can be a spouse a good friend your parents   just someone you know and trust in the family  and of course a good trusting friend.

report this to the MH Phyischrist and she/he will make a Referrl to the VA Sleep Clinic or free base it out to a private sleep study clinic   for a sleep study test , they will test you for sleep apnea and the severity of it  if you do have OSA (Sleep Apnea) they will prescribe you a C-PAP Machine in which to use every night as a necessity for your health and well being.

If you file the INT (Intent to file) you will have a year to file the sleep apnea claim  this gives you time to collect your medical records as evidence to submit with your Sleep Apnea Claim.

YOU CAN FILE IT SECONDARY TO YOUR S.C. PTSD

Base percentage for a Sleep Apnea Claim with C-PAP is 50%

I recommend you stay in treatment and discuss some of your OSA/Sleep Apnea to your therapist   get a paper trail started...and use as your evidence.

I agree with Doc25 as to what he mention in the above statement!

Edited March 9, 2019 by Buck52