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Do I have enough for secondary service connection?


Fat
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Question

I have always thought rhinitis  and sleep apnea had a casual relationship. In the past I asked two pulmonary doctors about the relationship, but they didn't see the connection. So I left the issue alone for years.

To my surprise after going through paperwork, I found a 2017 office visit note which confirmed my belief.

I initially had a sleep apnea test in 2014.  Afterwards I had surgery to remove the tonsils and tissue from nose (rhinoplasty). The surgery was to help with better air flow.

I went back to the doctor in 2016 to see if the surgery improved the sleep apnea.

The doctor's office visit notes stated, "patient is back to reassess since surgery. He still has significant symptoms and has a large amount of nasal congestion brought about by his atopic rhinitis. His atopic rhinitis leads to increased airflow resistance in the upper airway which also leads to airway collapse and would predispose the patient to apnea. He needs a follow up sleep study to reconfirm apnea.

I subsequentially had a another sleep test and was diagnosed with central sleep apnea.

I was service connected with Rhinitis in 2015.

After reading the 2016 notes, I called the sleep center to schedule an appointment with the doctor; however he is retired and playing golf in Arizona.

For secondary service connection I have a service connected disability, a diagnosis of sleep apnea, and it appears a nexus statement connecting the two.

Would the statement on the 2016 doctors note be sufficient?

 

All opinions are welcomed?

 

 

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For your nexus you need a doctor to state that they have reviewed all of your records, including service records and a statement that the apnea is at least as likely as not due to your SC rhinitis.  Without this you will most likely be denied.  It is usually the hardest hurdle to surmount when we try to get benefits with a private nexus.  We all have gone through this at one time or another.  Most civilian doctors will not do this for a SC nexus, this leaves you searching for a specialist in IME/IMO's who is not wary of the VA.  I really wish we could guarantee doctors that they will not be called up by the VA to testify as it is this that most doctors appear to be wary of.

 

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Vetquest is spot on. Your posted bio says you are rated now at 20%; SA with use of a CPAP machine diagnosed, is a 50% hit. If that is your symptoms, I'd recommend getting the IMO to submit. It could pull you up to a combined 60% rating. That would be IMO a pretty good investment.

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Ask your doctor to say the magic words:  "Your sleep apnea is at least as likely as not due to your SC rhinitis".  

Its like a password that is case sensitive..you wont get "in" unless you have the password.  Vetquest nailed it.  

Edited by broncovet
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5 hours ago, Fat said:

I have always thought rhinitis  and sleep apnea had a casual relationship. In the past I asked two pulmonary doctors about the relationship, but they didn't see the connection. So I left the issue alone for years.

To my surprise after going through paperwork, I found a 2017 office visit note which confirmed my belief.

I initially had a sleep apnea test in 2014.  Afterwards I had surgery to remove the tonsils and tissue from nose (rhinoplasty). The surgery was to help with better air flow.

I went back to the doctor in 2016 to see if the surgery improved the sleep apnea.

The doctor's office visit notes stated, "patient is back to reassess since surgery. He still has significant symptoms and has a large amount of nasal congestion brought about by his atopic rhinitis. His atopic rhinitis leads to increased airflow resistance in the upper airway which also leads to airway collapse and would predispose the patient to apnea. He needs a follow up sleep study to reconfirm apnea.

I subsequentially had a another sleep test and was diagnosed with central sleep apnea.

I was service connected with Rhinitis in 2015.

After reading the 2016 notes, I called the sleep center to schedule an appointment with the doctor; however he is retired and playing golf in Arizona.

For secondary service connection I have a service connected disability, a diagnosis of sleep apnea, and it appears a nexus statement connecting the two.

Would the statement on the 2016 doctors note be sufficient?

 

All opinions are welcomed?

 

 

I was service connected for both allergies and chronic sinusitis.  I got into the VA system so I could see and allergist and start allergy injections.  I also convinced the VA primary care doctor to order a sleep study.  The sleep study showed that I had mild sleep apnea and low oxygen while sleeping but I was just below the threshold of requiring a cpap.  I asked my primary care doctor if my allergies and sinusitis could cause sleep apnea and he said they were likely the cause of my sleep apnea and he wrote that in my records.  I did end up going to an outside neurologist who reviewed my sleep study and he said that what the VA ordered was inadequate so he ordered a new, more comprehensive sleep study.  The new study show i had moderate sleep apnea.  I submitted the new sleep study for my sleep apnea claim.  Based on the one sentence in my records where the doctor said my sleep apnea was likely caused by my allergies and sinusitis and my sleep study, I was service connected for sleep apnea.  

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I appreciate all the comments.

I will visit the sleep center where the 2016 study was done and hope the current doctor will be sympathetic.

The 2016 doctor has retired, but he was well known in the sleep study community.

Edited by Fat
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Will a DBQ or IMO be necessary for Sleep Apnea Claim?

The sleep study/lab report will be attached diagnosing SA with the nexus letter (hopefully).

The severity of the SA will be well documented on the report.

 

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Could my Primary Care Doctor provide a nexus?

He would:

1.  Have my complete medical records (including surgery notes to alleviate air flow issues) .

2.  A copy of the 2011 (OSA), 2016 (CSA), and 2020 (OSA) sleep studies.

3.  The office report of 2016 sleep doctor.

4.  Be able to provide a medical/professional opinion.

 

My primary doctor, ENT,  and 2016 sleep study doctor all were at the same facility.

Edited by Fat
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Fat I'd go for it. Your C&P examiner isn't likely to be a specialist either, so it would be equal in terms of professional background I would expect. The nexus must state that the CPAP not only is prescribed, but it is necessary for your well being, however. If you can get a supporting document from all 3 docs, that is even better. This is a 50% disability; the VA tries VERY hard to deny 50% claims. IMO.

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Even though your doctor has retired, I would think that the office could refer you to another specialist that could review your test and offer his/her opinion.

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Thanks.

I called the sleep center this morning and the doctor did complete the DBQ.

His nurse practitioner is working on the nexus letter.

I also scheduled a second sleep study (titration) to complete the process.

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@Fat I see that you mentioned that you had both CSA and OSA. I was given a diagnosis of OSA at the get go despite having more central apneas than obstructive because they "lumped' my hypopneas in with the OSA. Once I began treatment via BiPAP, the obstructive apneas went away and I still had persistent CSAs, which my VA sleep doctor stated was "more likely than not" connected to a service-connected TBI. Unfortunately, it seems that this was still denied despite the "magic words". 

I say all this because I honestly don't understand how the VA goes about awarding Sleep Apnea claims. I thought I had bullet-proof evidence, but I'll see what's missing once I receive the denial letters.

I'm also curious how you went from OSA to CSA to OSA again. Did the doctor have any opinions on that? CSA is a very rare issue when seen on its own because it usually is brought on by significant issues. However, if this was a CSA diagnosis while on CPAP, apparently it can be a negative reaction caused by CPAP use. I only mention this because they will try to fight on every angle and reading up on all the different forms of apnea has really helped me discuss things with my doctor that would have otherwise been overlooked. Obviously, it still hasn't paid off for me yet, but I hope you find success on landing the 50% rating!

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Thanks Bell Rung Boxer, LOL (what a name).

All of my first night test report OSA as fairly consistent.

The CSA mainly occurs on the second night of tritation while using the CPAP.

I have heard/read the use of a CPAP can cause a unusual reading regarding CSA.

I would suspect the VA is playing games with wording.

The initial sleep study is the true indicator of sleep apnea and if a CPAP mask can give a false CSA reading that should be noted.

 

I am going to submit the claim and let the chips fall where they may.

If I am denied, I will send it to the BVA.

 

I have been reading on the criteria for 50%.

You seem to have everything, but is a CPAP the only treatment option acceptable by the VA.

I SEE WHERE THE PHYSICIAN MUST NOTE: A CPAP machine is recommended/needed/necessary/essential for the treatment of the veterans OSA.

 

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3 hours ago, Fat said:

The CSA mainly occurs on the second night of tritation while using the CPAP.

I have heard/read the use of a CPAP can cause a unusual reading regarding CSA.

Yeah, this sounds like textbook "Treatment Emergent CSA". It's supposed to eventually go away in OSA cases after continued use with the CPAP, so if it dropped your amount of obstructives to be lower than the amount of centrals, that is proof positive that it is necessary. 

On my original sleep study with no PAP titration, I had 6 obstructive apneas, 19 central apneas, 2 mixed apneas and 31 hypopneas. Because of the inability to distinguish a "central hypopnea", they label them as obstructive and boom, I was labeled OSA. In my case though, the sleep doc noted that the amount of central apneas was abnormal and my obstructive apneas disappeared with my BiPAP ASV, while centrals lowered but were still persistent (AHI of 3.5 avg). Therefore, she deemed it "more likely than not TBI related CSA".  

3 hours ago, Fat said:

I SEE WHERE THE PHYSICIAN MUST NOTE: A CPAP machine is recommended/needed/necessary/essential for the treatment of the veterans OSA.

I believe this is the KEY for 50%. A word of caution on the word "recommended" though because I feel like it isn't strong enough. "Required" or the other words mentioned would be more definitive and not leave much wiggle room. 

However....PAP treatment may still end up being listed as an option because there are "mouth guards" that could be used for OSA. I have an extremely sensitive gag reflex and couldn't even stand a mouth guard in sports, so that was a no go for me. Not sure if a mouth guard would be effective for your situation, but if it isn't make sure the doctor notes it or try to find literature that suggests why it was not chosen for treatment. 

3 hours ago, Fat said:

is a CPAP the only treatment option acceptable by the VA

I do not believe the mouth guard counts for the 50%, but I could very well be wrong. As far as the CPAP, I read that the VA classifies other positive airway pressure devices (AutoPAP, BiPAP, etc.) as equivalent to a CPAP. 

Despite my VSOs hesitation due to my recent 100% P&T, I'll likely be heading to the BVA on my denial because if this apnea were to make me kick the bucket, I want the service connection.

I sincerely hope you don't have to do the same for your claim!

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NEVER GIVE UP.

Excellent post BellRungBoxer.

I called a CPAP provider and he explained the difference between CPAP, APAP, AND BPAP.

In addition, he also stated if the air pressure is too high during the titration, it would give a false reading regarding CSA.

TREATMENT EMERGENT CSA...............

Next, Depending on your type of apnea, that dictates the type of machine.

You were 100% percent correct on the VA classifying other devices as equivalent.

 

As far as the claim, I am going to submit what I have and if they deny, go directly to the BVA.

The doctor also noted the need for the CPAP on the DBQ.

The last sleep study, I had 57 Obstructive Apneas, 0 mixed apneas, and 2 central apneas.

The Central  Apneas increased during titration and the Obstructive Apneas went down.

 

Good luck BellRungBoxer and the BVA will get you victory.

When you get your decision, please post the grant or denial.

 

NEVER GIVE UP.............

 

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50 minutes ago, Fat said:

In addition, he also stated if the air pressure is too high during the titration, it would give a false reading regarding CSA.

Yes that was absolutely my case. Mask leaks are also a culprit of this. My centrals skyrocketed on the AutoPAP at it's lowest setting. I felt like it was choking me and made me feel like I was hyperventilating because of the force I had to use to exhale against the pressure.

Luckily, this sleep doc at the VA is perceptive and she moved me to the BiPAP ASV. It is apparently a much more expensive machine, so they don't suggest it often, but it has been a dream ever since. I can ramp down from 5.0 to 4.0 and the ASV automatically lowers the pressure when you go to exhale. Between that and the new mask they gave me (F&P Vitera full face) the experience is much more tolerable.

1 hour ago, Fat said:

Good luck BellRungBoxer and the BVA will get you victory.

So after getting my denial letter yesterday, I read through the evidence list (thanks hadit members!) and noticed that my Sleep Doc DBQ with her treatment notes with a positive nexus were not included, so I'll go with another supplemental and cross my fingers hard!

Let us know how your situation continues as well!

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