Table of Contents

CHAPTER 1: Managing a Veteran’s Disability 1
The VA Disability Rating System2
The VA Disability Adjudication System5
The VA Disability Benefits Rating Table9
CHAPTER 2: Independent Medical Opinion (IMO) and Nexus Letters for Disabled Veterans17
What is a Nexus? 17
What is an Independent Medical Opinion (IMO)? 17
Why Do Veterans Need an IMO/ Nexus Letter? 18
Requirements for an Adequate Medical Opinion – Why is a Veteran’s Primary Physician’s Opinion Often Insufficient?19
The Importance of Published Medical Reports (Treatises) in an IMO23
BVA Decision Held that Obstructive Sleep Apnea
(OSA) is Secondary to Posttraumatic Stress Disorder
(PTSD) Based on this Author’s IMO25
BVA Decision Held that OSA is Secondary to Asthma Based on this Author’s IMO26
CHAPTER 3: Total Disability Based On Individual Unemployability (TDIU) 27
TDIU Requires that a Veteran Be Unable to Secure Substantially Gainful Occupation27
Individual Unemployability – Consideration of Educational and Occupational History30
What is the Effective Date for TDIU? 31
Is VA Form 21-8940 “Veteran’s Application for Increased Compensation Based on Unemployability” Mandatory in a TDIU claim? 35
What is the Effect of a Favorable Social Security
Disability Decision on a Veteran’s Disability Claim? 36
CHAPTER 4: Sleep Apnea39

Service-connected Conditions That Cause
Obstructive Sleep Apnea (OSA) 39
What is Obstructive Sleep Apnea? 41
Rating for Sleep Apnea43
Development of Sleep Apnea During Military
Sleep Apnea Secondary to Service-Connected Sinusitis, Rhinitis or Deviated Septum47
Sleep Apnea Secondary to Service-Connected PTSD50
Sleep Apnea Secondary to Chronic Pain Syndrome56
Sleep Apnea Secondary to Narcotics Prescribed
for Service-Connected Conditions59
Sleep Apnea Secondary to Service-Connected
Sleep Apnea Secondary to Service-Connected
Chronic Obstructive Airway Disease (COPD) or
Sleep Apnea Secondary to Service-Connected Gastroesophageal Reflux Disease (GERD) 66
Sleep Apnea and Obesity68
Sleep Apnea Secondary to Service-Connected
Diabetes Mellitus70
Sleep Apnea Secondary to Service-Connected Stroke
and Ischemic Heart Disease71
Sleep Apnea Secondary to Service-Connected
Cervical Spine Abnormalities72
Migraines Secondary to Service-Connected
Sleep Apnea75
Hypertension Secondary to Service-Connected
Sleep Apnea75
Sleep Apnea Secondary to Service-Connected Fibromyalgia76
Upper Airway Resistance Syndrome (UARS) 77
Sleep Apnea Caused by Antidepressants78
Sleep Apnea and Interstitial Lung Disease81
Sleep Apnea and Cardiovascular Disease (CVD) 83
Sleep Apnea and Headaches/Migraines85

CHAPTER 5: Orthopedics87

Posttraumatic Osteoarthritis87
The BVA Accepted This Author’s IMO Regarding Osteoarthritis92
Understanding the Rating of Knee Injury93
Knee Anatomy94
Knee Conditions94
Limitation of Motion97
Evaluation of Pain102
How is the Functional Assessment of Joints
Conducted? 104
Combined Rating and the Rule Against
Proposed Amendment to the Rating of
Musculoskeletal Conditions109
Understanding the New Rating Table for Cervical
and Lumbar Spine Disability113
What is Intervertebral Disc Syndrome (IVDS)? 115
The pertinent anatomy for IVDS115
Cause of IVDS117
Symptoms of IVDS117
Diagnosis of IVDS119
Treatment of IVDS120
Rating for IVDS122
Incapacitating Episodes124
What Does a VA Examiner Look for in
Musculoskeletal Rating? 126
Signs Suggesting that a Veteran is Malingering
or Exaggerating His Symptoms127
Degenerative Joint Disease Rating Based on
Objective Tests129
Sciatic Nerve Function129
Common Peroneal Nerve Function130
How do the New Evaluation Criteria for IVDS
Compare to the Old Criteria? 131
Over evaluations132
Ankle injury in paratroopers – Tarsal Tunnel
Rating for Shoulder Disability137

CHAPTER 6: Cardiology141

Atherosclerosis and Coronary Risk Factors141
Elevated Cholesterol Levels During Service
Leads to Coronary Artery Disease142
Rating of Coronary Artery Disease143
The Value of Stress Testing145
Stress Testing and METS145

CHAPTER 7: Gastrointestinal System155

Irritable Bowel Syndrome (IBS) Secondary
to Service-Connected Posttraumatic Stress
Disorder (PTSD) 155
Crohn’s Disease158
Establishing the Diagnosis of Crohn’s
Disease and Evaluating Disease Activity159
Stress Can be a Contributing Factor in
Crohn’s Disease160
Fatty Liver161
Gastroesophageal Reflux Disease (GERD) 163
CHAPTER 8: Neurology166

Traumatic Brain Injury (TBI) 166
Brain Injury Severity169
TBI Residuals171
Posttraumatic Headaches173

CHAPTER 9: Rheumatology179

Chronic Fatigue Syndrome and Fibromyalgia179
Systemic Lupus Erythematosus188
Antinuclear Antibody Test189
Rheumatoid Arthritis193
Pathogenesis of Rheumatoid Arthritis195
Clinical Features of Rheumatoid Arthritis196
Constitutional Features of Rheumatoid
Carpal Tunnel Syndrome in Rheumatoid

CHAPTER 10: Endocrinology198

Diabetes Mellitus – Etiology and Classification198
Diagnosis of Diabetes Mellitus199
BVA Decision Regarding Service
Connection for Diabetes Mellitus202
Inhaled Corticosteroids and the Risk of
Diabetes Onset and Progression204
Diabetes and Renal Failure204
Hypertension and Diabetes Mellitus206
Diabetic Cataracts207
Prostatic Hypertrophy and Diabetes

CHAPTER 11: Psychiatry210

Winning a Claim for Posttraumatic Stress
Disorder (PTSD) Benefits210
What Did the VA PTSD Study Find? 211
What is Posttraumatic Stress Disorder (PTSD)? 213
Does a Veteran Need to Prove That He/She
Was Involved in Combat for a PTSD Claim215
What Evidence is Required to Prove Combat
Stressors? 220
What Evidence is Required to Prove a Personal or
Sexual Assault? 222
Is the Veteran’s Own Testimony Sufficient to
Establish a Stressor? 224
Alcohol and Drug Abuse in PTSD Cases225
Psychological Testing in PTSD Claims226
Rating Considerations for PTSD228
Hypertension Secondary to PTSD232

CHAPTER 12: Toxicology237

Agent Orange237
Oral Cancer Caused by Exposure to Agent Orange240
Myelodysplastic Syndrome (MDS) Due to
Exposure to Agent Orange244
Hypertension, Vascular Disease and Chronic
Respiratory Diseases Due to Exposure to
Agent Orange247
Bladder Cancer Due to Exposure to Agent Orange248
Prostate Cancer and Trichloroethylene (TCE)
Parkinson Disease and Trichloroethylene (TCE)
Camp Lejeune255
Gulf War Syndrome259

CHAPTER 13: Erectile Dysfunction264

Erectile Dysfunction Secondary to Hypertension267
Erectile Dysfunction Secondary to Sleep Apnea268
Erectile Dysfunction Secondary to PTSD268
Diabetes is an Established Risk Factor for
Sexual Dysfunction270

CHAPTER 14: Claims for Disability Due to VA Negligent Care Pursuant to U.S.C.S. 1151272

CHAPTER 15: Proposed Reduction in VA

APPENDIX A: CV David Anaise M.D., J.D284

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