historic diagnose will VA Accept one 10 years old?

[Buck52]

Question

Will the va take an older diagnose that was in the veterans medical records? say 5/10 years ago?

Like a Veteran was diagnose for Sleep apnea back in 2010...but never filed a claim for it   now this veteran wants to put in a claim for it.

He uses  the VA PRESCRIBE  C-PAP

He has a Mild Diagnose for Sleep Apnea  but no where in his records does it say is medically required...so under the M-21  it says must necessary medically to use''

the manual now says,

“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.

He never had OSA in military  but has it now years later after separation due to his PTSD. 

His VA M.H. Phyistrist Suggested he see the VA sleep clinic & he did a sleep study  and they diagnose him with the Mild OSA and gave him a  C-pap TO USE (*THIS WAS 10 YEARS AGO*) But no where I can find in his records the Dr said it is medically necessary to use''??

I mention to him they will go by the date he filed his claim for sleep apnea  but we have not filed it yet...I am trying to get all his T's  and I's crossed  we don't want a denial.

How will he over come the new regulation in M-21 below

“Use absent a medical determination that the device is necessary does not qualify.

I am thinking he needs a Sleep Dr  or a Qualified Dr to render his medical opinion that the C-pap machine is medically ''REQUIRED'' this veteran is necessary to use his c-pap machine prescribe by the VA

We are going to file a secondary to his PTSD. AS SOON AS I CAN GET HIM TO SEE A SPECIALIST OPINION FOR THE C-PAP MACHINE REQUIRED USE AND MEDICALLY NECESSARY TO USE FOR HIS WELL BEING 

Need some opinions on this please.

[brokensoldier244th]

Sure, if he bought the cpap himself, but if it's prescribed by VA they expect it to be used. They wouldn't have prescribed it if it medically necessary.

[Buck52]

It may surprise you to learn that the VA actually has a series of written policies on how to decide VA disability claims.  This huge document is a “playbook” for VA personnel to use in deciding every type of VA claim.

That playbook is M21-1MR Adjudication Procedures Manual.  The M21-1MR is constantly being updated in a piecemeal fashion.  One of those most recent updates was the section dealing with the adjudication of VA sleep apnea disability claims.

Beware This Pitfall in VA Sleep Apnea Claims

One of the two changes makes it a little easier for the Regional Office to deny your VA sleep apnea claim at the 50% disability rating level.  The diagnostic criteria for a VA sleep apnea claim, found in the Code of Federal Regulations, have not changed.  For a 50% rating, the diagnostic criteria still “Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine.”

But, with these changes in the VA playbook, VA is placing a greater emphasis on what is meant by the word “required.”  Look at this new language in the m21-1MR:

“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.”

A little bit later on, the manual now says,

“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.”

That last phrase should be a warning – and a clue – to you.  In the past, if you presented evidence that your doctor prescribed a CPAP machine to help with your sleep apnea that was sufficient evidence in the eyes of VA for a 50% VA sleep apnea rating. VA personnel were like me; they assumed doctors did not prescribe anything that was not medically necessary.

So, a prescription for a CPAP was proof that it was required for treatment of sleep apnea.  Now, you need more than that because VA refuses to assume anything.

[blahsaysme2u]

buck didnt you just post this on my post?  maybe this will help explain? it made sense to me. even though it doesnt make sense in general, but at least the explanation of the va policy is explained well. hahaha

https://veterans.perkinslawtalk.com/post/bad-secret-change-to-va-sleep-apnea/

[Buck52]

The VA is cracking down hard on sleep apnea claims  its not like it use to be...get a sleep study done and if you have S.A.  VA will diagnose you for Sleep apnea and issue you a C-pap machine  (''Automatic 50%) use of a C-pap  machine (not true anymore) ...even if they say its  Required necessary to use   can still be denied 

[Buck52]

4 minutes ago, blahsaysme2u said:

buck didnt you just post this on my post?  maybe this will help explain? it made sense to me. even though it doesnt make sense in general, but at least the explanation of the va policy is explained well. hahaha

https://veterans.perkinslawtalk.com/post/bad-secret-change-to-va-sleep-apnea/

Yes I did  I just found out this info myself...looking at this Veterans medical records  I can't find where the Dr says its medically necessary 'required to use for his well being.

I think the VA Sleep clinic mention'' you have been diagnose for Mild Sleep apnea and will Require a C-PAP to use.''...  this won't fly for a claim.

[Vync]

Medicare has a definition of "medically necessary: 

https://www.medicare.gov/glossary/m

Quote

Medically necessary

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

 

Also check these which are from 38 CFR that discuss what is considered medically necessary:

https://www.law.cornell.edu/cfr/text/38/17.38

https://www.law.cornell.edu/cfr/text/38/17.272