Do I have enough for secondary service connection?

[Fat]

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?

 

 

[bellrungboxer]

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!

[Fat]

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.............

 

[bellrungboxer]

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!