Sleep Apena denied

[Berta]

This is from a poster on my profile-

"JaeNobe said:

I was denied OSA claim secondary to Depression and Chronic Pain. I have an IMO from David Anise connecting it to my service related injuries and depression, Sleep Dr. put I my C-Pap was a necessity.  I have a c-pap. Even, submitted the NIH Sleep Disorder study.   I do not have my letter stating why the denied it Im pretty sure its because of the VA's PA that half way did my C&P (5 mins) said that she believed it wasnt.  It was I want to appeal but not sure what the best ave is to do so. Do I hire a lawyer (if so, who do you recommend)? Do I use DAV, VSO. I've seen someone say ask them to send to BVA.  I'm at a complete lost as to what my next step should be. "

 

[JaeNobe]

Here is the C&P (mind you it only lasted 5 minutes and I told her it effects my job but she marked it No on the DBQ) She never measured my neck or said that she read anything in my file. I went in and it was like she already had it set that she was going to write an unfavorable examination. Thats why I was confused on why they would send me to General Med and to a PA and not an actual Sleep clinic or doctor.

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:

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

1. 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:

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.

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:

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

 

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-sleepapnea-

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-obstructivesleepapnea-

in-adult

s?source=search_result&search=SLEEP+APNEA&selectedTitle=1%

7E150

#H760186

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

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

*********

[Berta]

Good, they LIED about this:

"The submitted statement from Dr. XXXXX opined that yourmedications associated with the treatment of your service connected depressivedisorder assisted in causing your obstructive sleep apnea.

The evidence shows no medication treatment for any mental health condition prior to or at the time of your diagnosis of obstructive sleep apnea. "

This is probably just BS the examiner threw in:

"?CHAPTER PROCEDURE ENTERING ALCOHOL COUNSELLING FOR

INCREASED ETOH USE

(???)"

I believe this is definitely a CUE now----however it would have helped if Dr. Anaise gave some specifics on the meds you take. But with the BVA award I got above, I believe he certainly felt his IMO was strong enough.

Can you tell us what meds you take so we can see which ones could cause or aggravate the Sleep Apnea?

This stuff really pisses me off..I was victimized by similar lies and non medical inaccurate statements by VA doctors, in just about every claim I filed.

The two hyperlinks the examiner used are crap-

This one might be better:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610889/

I need to read it over- there are more but I am pressed for time----

I will try to prepare a CUE for you, that might make this go faster than a reconsideration....

Have you googled the examiner's name to see what their credentials are?

Then again I think you said they were a PA?

I knocked down a PA's opinion and a few VA doc opinions many times.....

If the examiner  really knew anything about sleep apnea they would have used far better links then they mentioned.

 

 

 

[JaeNobe]

3 minutes ago, Berta said:

Good, they LIED about this:

"The submitted statement from Dr. XXXXX opined that yourmedications associated with the treatment of your service connected depressivedisorder assisted in causing your obstructive sleep apnea.

The evidence shows no medication treatment for any mental health condition prior to or at the time of your diagnosis of obstructive sleep apnea. "

This is probably just BS the examiner threw in:

"?CHAPTER PROCEDURE ENTERING ALCOHOL COUNSELLING FOR

INCREASED ETOH USE

(???)"

I believe this is definitely a CUE now----however it would have helped if Dr. Anaise gave some specifics on the meds you take. But with the BVA award I got above, I believe he certainly felt his IMO was strong enough.

Can you tell us what meds you take so we can see which ones could cause or aggravate the Sleep Apnea?

This stuff really pisses me off..I was victimized by similar lies and non medical inaccurate statements by VA doctors, in just about every claim I filed.

The two hyperlinks the examiner used are crap-

This one might be better:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610889/

I need to read it over- there are more but I am pressed for time----

I will try to prepare a CUE for you, that might make this go faster than a reconsideration....

Have you googled the examiner's name to see what their credentials are?

Then again I think you said they were a PA?

I knocked down a PA's opinion and a few VA doc opinions many times.....

If the examiner  really knew anything about sleep apnea they would have used far better links then they mentioned.

 

 

 

Thank you SO MUCH Berta your help and links are a great help.

Yes Ill list the medications in a few minutes.

Also, Im looking for the statement from the VA Sleep Clinic that also listed my medications and stated that it is a nessesity I use my C-Pap. Ill post that as well. 

Again, thank you for your support and help!

[Berta]

I have to leave to get prepared for that conference call between Sec Wilkie and the President on the new Missions Act.

If I am lucky enough to get picked for a question I want it to be a good one.....I have a concern about the Urgent Care provision of the Act.

 

 

[JaeNobe]

CYCLOBENZAPRINE - Since 2003. Was diagnosed with OSA in 2006

Currently on

CYCLOBENZAPRINE

CITALOPRAM HYDROBROMIDE 

 

https://www.va.gov/vetapp14/Files4/1427494.txt

Although the March 2014 opinion was negative regarding any potential etiology for a nexus between OSA an the benzodiazepines the Veteran used for his psychiatric condition, the Board finds that the opinion actually provides a basis for granting the claim on the basis of aggravation, under the benefit of the doubt standard. Gilbert, 1 Vet. App. At 54. The examiner acknowledged that sleep apnea may be aggravated by these medications. While she stated that there was no evidence to support a relationship between the medication and the diagnosis, the examiner did not to discuss the timeframe regarding the cyclobenzaprine (a benzodiazepine) treatment in regard to the onset of symptomatology, and the OSA diagnosis. As such, the rationale for the negative etiology opinion is partly undermined. See Nieves-Rodriguez v. Peake, 22 Vet. Peake, 22 Vet. App. 295, 302 (2008) (holding that a medical opinion that is not factually accurate, fully articulated, or based on sound reasoning, is no probative). The fact, however, does not undermind her acknowledgement that benzodiazepines may aggravate OSA

 

Edited June 25, 2019 by JaeNobe

[Berta]

I am trying to develop a CUE and it will take time- 

 

when did the VA first diagnose the depression as service connected to the IVD?

Also when did the VA first prescribe the Celexa® (citalopram HBr)