What is sleep apnea?

Obstructive sleep apnea (OSA) (ICD-9-CM 327.23) is the most common form of sleep apnea and is caused by an airway blockage that occurs when the soft tissue in the back of the throat narrows or closes during sleep. The brain then senses the inability to breathe and briefly arouses the person to begin breathing again.  True obstructive sleep apnea occurs when tissues block the upper airway (e.g. large adenoids, deviated septum).

Central sleep apnea (ICD –9-CM 327.27) occurs when the brain does not send proper signals to the muscles that control breathing which results in the person awakening with shortness of breath.

Complex or mixed sleep apnea is a combination of both obstructive and central sleep apnea.

As mentioned earlier, pure obstructive sleep apnea involves abnormalities of the upper airway such as enlarged tonsils, large tongue or blocked nasal passages.  Interestingly, in all these cases there is no mechanical blockage to the airway during wakefulness; obstruction occurs only during sleep.  Thus, it is clear that in obstructive sleep apnea cases, the brain is also involved.  The brain does not send proper signals to the muscles that control breathing during sleep.  Thus, all sleep apnea cases are in fact mixed sleep apnea.  I have yet to encounter a single case, however, that was not diagnosed as obstructive sleep apnea.  Obstructive sleep apnea has become the term of art for all sleep apnea.  For rating purposes, the rating table does not distinguish between obstructive, central and mixed sleep apnea.

OSA patients were shown to maintain their upper airway patency in wakefulness via a compensatory, augmented EMG activity of their airway dilator muscles, during wakefulness [and non-rapid eye movement (NREM) sleep].  Remarkably, sleep apnea patients experience little or no problems with their breathing or airway patency while awake.  In fact, the great majority of people with sleep apnea possess ventilatory control systems that are capable of precise regulation of their alveolar ventilation and arterial blood gases with extremely small variations from the norm.  Electrical activity from medullary inspiratory neurons, and EMG activity of diaphragm and abductor muscles of the upper airway in healthy humans show reductions in amplitude upon the transition from awake to NREM sleep, usually accompanied by a mild to moderate hypoventilation and two- to fivefold increases in upper airway resistance.

A fast and highly variable breathing frequency is a hallmark of rapid eye movement (REM) sleep in mammals.  An excitatory drive to breathe is common in REM, with increased diaphragmatic EMG activity and increased activity in many medullary respiratory neurons above those levels observed in NREM sleep or quiet wakefulness.  In REM sleep, there are both tonic excitatory inputs and phasic inhibitory inputs in the brain respiratory centers that account for irregularities in breathing pattern, as well as the loss of excitation, which contributes to hypotonia of the muscles of the upper airway.  This results in collapse of the airway leading to sleep apnea.

Pace-Schott et al. reported in Sleep and REM sleep disturbance in the pathophysiology of PTSD: the role of extinction memory:

“Fluoro-deoxyglucose PET imaging shows that fear-conditioning and extinction are located in the amygdala and dorsal anterior cingulate cortex (dACC) and other areas associated with memory for the extinction (inhibition) of this fear (an “extinction memory network”) that includes the hippocampus and ventromedial prefrontal cortex (vmPFC).

The “anterior paralimbic REM activation area” overlaps with fear and extinction circuits. Fluoro-deoxyglucose PET image of areas that reactivate during REM sleep following relative quiescence during NREM sleep…Walker and colleagues suggest that REM sleep serves the dual purpose of consolidating the content of emotional memory and diminishing the memory’s emotional charge. Similarly, regulation of mood and working through of emotional responses to intra- and interpersonal stressors have been linked with REM sleep and associated dreaming. Significantly, a broad anterior midline area of cortex and subcortex (the “anterior paramedian REM sleep activation area” selectively activates during REM sleep following relative deactivation during non-REM (NREM) sleep, and this region encompasses both the fear expression and extinction memory networks.

 

 

 

 

 

 

 

 

Normal anatomy while awake

 

 

There are two basic mechanisms for obstructive sleep apnea.  The first is static narrowing of the airways due to swelling of structures that block the airway.  Some examples are septal deviation of the nose, or accumulation of fat in the retro pharynx noted in certain types of obesity.  The second, and more frequent reason for sleep apnea, are dynamic processes that involve the muscle tone, mostly of the tongue due to hypotonia of the genioglossus muscle.

Jordan et al.^[i] published a study: Airway Dilator Muscle Activity and Lung Volume During Stable Breathing in Obstructive Sleep Apnea:

“Obstructive sleep apnea (OSA) is a common disorder, characterized by repetitive upper airway collapse during sleep.  Upper airway collapse in OSA is thought to occur at sleep onset because of the reduction of activity of several upper airway dilator muscles, which then do not hold the anatomically vulnerable airway open.

The severity of OSA varies throughout the night and between sleep stages.  Generally, obstructive respiratory events are more common and longer in REM than NREM sleep.”

The picture above demonstrates how the tongue plays a major role in airway obstruction, especially if one breathes through the mouth rather than the nose.  When the tongue muscle (the genioglossus) tone is deactivated ore relaxed, the tongue will slip backwards and obstruct the airway.  Jordan et al. have shown that when patients with OSA spontaneously overcome their tendency for airway collapse and have stable breathing during sleep, the genioglossus muscle is more active than during disordered breathing events.

Many patients with obstructive sleep apnea (OSA) have spontaneous periods of stable flow limited breathing during sleep without respiratory events or arousals. In addition, OSA is often more severe during REM than NREM and more severe during stage 2 than slow wave sleep (SWS). The physiological mechanisms for these observations are unknown. Thus we aimed to determine whether the activity of two upper airway dilator muscles (genioglossus and tensor palatini) or end-expiratory lung volume (EELV) differ between (1) spontaneously occurring stable and cyclical breathing and (2) different sleep stages in OSA.

 

“Electrical activation of the genioglossus muscle or hypoglossal nerve is known to dilate the retroglossal airway and reduce the pharyngeal critical closing pressure in humans. Thus, it would appear likely that the increased genioglossus muscle activity is playing a causal role in contributing to the sleep stage and time of night differences in the severity of OSA…

Prior research has shown that the genioglossus is activated by chemoreceptor stimulation and by reflex activation in response to negative pressure. There is also evidence to suggest that the genioglossus receives an independent stimulation during wakefulness which is lost at sleep onset and is known as the ‘wakefulness stimulus’.”

Sleep Stage Effects

The “normal” sleep-onset latency is approximately 10 minutes.  The “normal” sleep stage distribution is 5% stage I; 50% stage II; 15-25% stage III, slow wave or deep sleep (SWS); and
20-25% stage REM.

The activity of the genioglossus has previously been reported to be higher during SWS than stage II sleep.  The high arousal threshold that occurs during deeper stage II can allow large genioglossus muscle activity to develop, stabilizing the airway such that sleep can continue and SWS can develop.

Respiratory events are often worse during REM than NREM sleep.  Jorden et al. found that the tonic (expiratory) activity of the genioglossus was reduced during respiratory events in REM compared to stage II sleep.  This reduction in tonic genioglossus activity may contribute to the predisposition to airway collapse that occurs in REM because airway collapse typically occurs at the end of expiration.  During REM sleep, further suppression of the tonic component of the genioglossus activity was observed, potentially contributing to the increased severity of OSA in REM sleep.

 

 

 

 

OSA secondary to Veteran’s service-connected Posttraumatic Stress Disorder (PTSD)

It is my expert medical opinion that the veteran’s sleep apnea is more likely than not secondary to his service-connected PTSD.  It is well established in the scientific literature that sleep apnea in a veteran is more likely than not secondary to PTSD; 47.6% of combat veterans with PTSD were found to have OSA compared to only 12.5% of healthy controls.^[ii]

Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel.^[iii]  In an article, Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel, Mysliwiec et al, observed that sleep disturbances are increasing in frequency and are commonly diagnosed during deployment and when military personnel return from deployment (redeployment).^[iv] [Exhibit 3]  Recent evidence suggests the increased incidence of sleep disturbances in redeployed military personnel is potentially related to PTSD, depression, anxiety, or mTBI^[v]:

“Medical comorbidities were frequently identified in military personnel undergoing PSG (sleep study), with 58.1% having one or more service-related illnesses.  The percentages of military personnel with PTSD (13.2%) and mTBI (12.8%) are similar to previous reports, whereas a larger percentage of those in the study’s study had depression (22.6%) and anxiety (16.8%).^[vi]…Further, the sleep disturbances of insomnia and nightmares can persist despite appropriate therapy for PTSD…”

About 26% to 31% of veterans in the U.S. are estimated to be affected by posttraumatic stress disorder (PTSD) in their lifetime.  Individuals with PTSD often report sleep disturbances including trouble in falling and maintaining sleep, recurrent nightmares about trauma, and other disruptive nocturnal behaviors such as anxiety and night terrors during sleep.^[vii] [Exhibit 4] Veterans with PTSD have a higher prevalence of obstructive sleep apnea (OSA) than the general population.  Untreated OSA accentuates the sleep-related symptoms of PTSD, especially the number and intensity of nightmares, repeated awakenings, difficulty falling back to sleep, and increase in daytime sleepiness and tiredness.  A growing body of evidence suggests that disturbed sleep is more likely to be a core feature of PTSD rather than just a secondary symptom.  Hypoxia, sympathetic discharge from respiratory disturbances, dysfunctional REM sleep, and abnormal REM mechanism have been proposed as a mechanism for sleep apnea in PTSD patients.

Kobayashi et al. conducted a meta-analytic review of 20 polysomnographic studies comparing sleep in people with and without PTSD.  Results^[viii] showed that PTSD patients had more stage 1 sleep, less slow wave sleep, and greater rapid-eye-movement density compared to people without PTSD.

A recent study showed that treatment of OSA with CPAP is associated with a decrease in the number of nightmares and daytime sleepiness in PTSD patients.  This study also showed a positive correlation of REM sleep percentage with the number of nightmares.  This supports the conclusion that dysfunctional REM sleep mechanism may be involved in the pathogenesis of PTSD.  Just as in obesity (see below) there is a bidirectional relationship between sleep apnea and PTSD.  PTSD, especially during nightmares, causes sleep apnea.  Treatment of sleep apnea ameliorates the severity of PTSD.  As REM is central to both conditions, sleep apnea and PTSD, the relationship is quite clear.  A recent study reported that REM, AHI and interrupted sleep at night were independent predictors of nightmares in OSA patients, and CPAP therapy results in significant improvement in nightmare occurrence.  Apparently when a patient spends more time in REM the likelihood of having nightmares becomes higher.  REM suppression with prazosin, an α-1 inhibitor, showed improvement in combat-related PTSD nightmares and sleep quality in active-duty soldiers in a recent trial.  This may indicate that suppressing the “dysfunctional REM” in PTSD patients may have helped reduce symptoms.

The subjective sleep disturbance in posttraumatic stress disorder (PTSD), including the repetitive, stereotypical anxiety dream, suggests dysfunctional rapid eye movement (REM) sleep mechanisms.  The polysomnograms of a group of physically healthy combat veterans with current PTSD were compared with those of an age-appropriate normal control group. Tonic and phasic REM sleep measures in the PTSD subjects were elevated on the second night of recorded sleep.  Increased phasic REM sleep activity persisted in the PTSD group on the subsequent night. During the study, an anxiety dream occurred in a PTSD subject in REM sleep. The results are consistent with the view that a dysregulation of the REM sleep control system, particularly phasic event generation, may be involved in the pathogenesis of PTSD.^[ix]

 

Obesity and Sleep Apnea

As to the impact of obesity on OSA, while obese patients have a higher incidence of sleep apnea  (12%) compared to the general population (4%), the incidence of sleep apnea in obese patients is lower than that reported for PTSD and mood disorder.

In the study Obesity: epidemiology and clinical aspects, Xavier Formiguera, M.D., Ph.D., reported^[x] :

“ Obese individuals have a narrowing of the upper airway due to an extrinsic soft tissue enlargement because of fat deposits in the posterolateral oropharyngeal area. Patients with central type obesity are more prone to have OSA because of their fat accumulation pattern (visceral and trunk). Waist circumference and visceral fat area correlates with the severity of OSA, more so than BMI. Besides the anatomical changes that may occur in the oropharyngeal region of the obese, the central nervous system (CNS) plays a crucial role in the pathogenesis of OSA. The decrease of the CNS activity during the rapid eye movement (REM) phase of sleep results in a decrease in the diaphragmatic and oropharyngeal muscle activity which facilitates the airway collapse.”

The critical issue to understand is that the mechanism of the development of sleep apnea is the same in both obese patients and in patients suffering from PTSD.  In both cases there is an alteration of sleep and the involvement of REM sleep.  Thus, both conditions work in synergy to cause sleep apnea.  To argue that only obesity causes sleep apnea is then incorrect.  Obesity and PTSD in combination are far more likely to cause sleep apnea then either condition alone.  Thus, the effect of one of these conditions on OSA cannot be scientifically segregated from the other.

Furthermore, there is a bidirectional effect  between sleep apnea and both conditions. Treatment of sleep apnea by CPAP ameliorates the symptoms of PTSD, especially nightmares, and CPAP also results in reduction of weight.  Thus, the finding that there is a by directional effect between PTSD and obesity with sleep apnea, cannot be interpreted as a lack of causation of either obesity or PTSD of sleep apnea.

Conclusion

After reviewing all of the veteran’s medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is secondary to his service-connected Posttraumatic Stress Disorder (PTSD).  The scientific observation that the derangement of REM sleep prominent in the PTSD patient is the cause for sleep apnea is of particular importance in this case.  Sleep apnea requiring treatment by CPAP warrants a 50% rating.

6847  Sleep Apnea Syndromes (Obstructive, Central, Mixed):
Chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy	100
Requires use of breathing assistance device such as continuous airway pressure (CPAP) machine	50

 

 

Sincerely,

 

David Anaise, JD, MD

BVA approves OSA due to PTSD based on Dr Anaise’s IMO

DEPARTMENT OF VETERANS AFFAIRS
Board of Veterans’ Appeals
Washington DC 20420
DOCKET NO. 11-01922 MAR 2 8 2016

On September 2012 VA examination, the diagnosis was obstructive sleep apnea.
The examiner reported that he found no valid medical literature to support the claim that sleep apnea is proximately due to or the result of PTSD. Therefore, the examiner opined that it was less likely as not the Veteran’s sleep apnea was caused by or a result of his PTSD. A June 2014 letter from Dr. D. Anaise included an opinion that the Veteran’s sleep apnea was more likely than not secondary to his service-connected PTSD. The letter cited medical literature as evidence in support of the opinion, and included such medical literature in support of the Veteran’s claim. Such evidence was also in support of a causal relationship between sleep apnea and PTSD. After a review of the evidence of record, resolving all reasonable doubt in the Veteran’s favor, the Board finds that the preponderance of the evidence supports that the Veteran’s obstructive sleep apnea is secondary to his service-connected PTSD. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.310. The Board notes that the September 2012 VA opinion against the Veteran’s claim cited the lack of medical literature in support of a causal relationship between PTSD and sleep apnea as a basis for concluding the Veteran’s sleep apnea was less likely as not caused by or a result of his PTSD. In contrast, the June 2014 letter from Dr. D. Anaise indicated there was a significant volume of medical literature to support the Veteran’s claim, and cited to such evidence in support of his opinion that the Veteran’s obstructive sleep apnea was more likely than not secondary to his service-connected PTSD.
The Board finds the June 2014 letter and opinion from Dr. D. Anaise to be more probative and persuasive in this case as it was based on a review of the Veteran’s treatment records, cited supporting medical literature, and was provided by a medical expert competent to provide an opinion as to the etiology of the Veteran’s sleep apnea. Hence, entitlement to service connection for obstructive sleep apnea as secondary to service-connected PTSD is warranted

Veteran Disability Claims: Nexus and IMO Letters

 anaisedavid.office@gmail.com

I provide Independent medical opinion ( IMO Letters) to disabled veterans

In addition to being a lawyer I am an academic transplant surgeon with almost thirty years of medical experience.  I provide Independent Medical Opinions (IMO Letters) to disabled Veterans in a form of a Nexus letter combining the best medical analysis and research with knowledge of the veteran’s disability law.  My purpose is to provide you with a nexus letter which will convince the DRO or the BVA judge that you are indeed disabled due to injuries incurred during your military service

What is Nexus?

There are three steps involved in a claim for service connection. a. First, the veteran must present satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease . Second, the VA must determine whether that evidence is consistent with the circumstances, conditions, or hardships of such service. The third and final requirement is demonstrating that there is a nexus (a link or a connection) between the current disability and the event that occurred during the period of military service.

What are IMO Letters?

To meet the nexus requirement, the veteran must have an evaluation by a physician that will establish that the veteran is indeed disabled and also that his disability is as likely as not caused by his military service.  There are two methods used to establish such a nexus; one is independent medical examination and the other is independent medical opinion.  The first involves an actual examination of the veteran at the doctor’s office.  The second method does not require a physical examination, but does require an experienced physician who will carefully review the entire medical record and the C&P examination, and then perform independent and thorough medical research relevant to the issues of the veteran’s case.  The expert drafts an analysis of this information, presenting the medical history in a way that best supports the claim.

Why do I need Nexus / IMO Letters for my Veteran Disability claim?

The Institute of Medicine (IOM) was asked by the Veterans’ Disability Benefits Commission to study and recommend improvements in the medical evaluation and rating of veterans for the benefits provided by the Department of Veterans Affairs (VA) to compensate for illnesses or injuries incurred in or aggravated by military service The IOM noted that inadequacy of the raters employed by the VA: “Few raters have medical backgrounds. They are required to review and assess medical evidence provided by treating physicians and VHA examining physicians and determine percentage of disability, but VBA does not have medical consultants or advisers to support the raters. Medical advisers would also improve the process of deciding what medical examinations and tests are needed to sufficiently prepare a case for rating” General (OIG) reported that 24 percent (95,000 of 405,000) of the C&P examinations had been incomplete in FY 1993, a percentage that had not improved much in FY 1996, when 22 percent were incomplete (VA, 1997b). The IOM found also that For example, of the spine exams requested during the second quarter of fiscal year 2005, 32 percent of the exam requests had at least one error such as: •not identifying the pertinent condition; •not requesting the appropriate exam;

What I do:

1) I  Review medical charts and service records to establish service connection

2)  I Review medical records and C&P examinations to establish appropriate ratings

3) I Research BVA and CAVC archives for electronic records relevant to your case

4) I Perform detailed research of medical literature

5) I write a detailed nexus letter summarizing your medical records, the veteran claim file, and provide a medical analysis using the latest medical scientific literature as well as analysis of the Veteran rating table.  I include exhibits which facilitate the review of your case by the DRO or the BVA judge

What is the cost of  Independent Medical opinion (Nexus / IMO Letters) ?

This is a service which I provide as a physician rather than a lawyer .  As such I do not collect a percentage of the past due benefits if we win but rather need to be paid upfront.  The typical cost is $1500

What we do not do:

I do not perform physical exams.  This would best be done by a personal physician.

Samples of my Independent Medical opinion ( IMO/Nexus)

One of my clients posted the IMO I wrote for him.  see the sample

To further assess the quality of my medical and legal analysis  I can  share with you  briefs of cases I  litigated before the Court Of Appeals   ( CAVC ) see also Representation before the Court of Appeals for Veterans CAVC

RK v. Shinseki

MU v. Shinseki 09-3570

EW v. Shinseki 12-2155

HH v. Shinseki 11-1612

The names of the clients have been adducted

 

What our clients say about our Independent Medical opinion (Nexus / IMO Letters) ?

The VAWatchdog.org recommendations for IMO 

The Independent Medical Examination & Independent Medical Opinion VAWatchdog recommends that every veteran consider seeking an Independent Medical Examination (IME) or an Independent Medical Opinion (IMO) for their VA disability benefits claim. The VA has become increasingly difficult to navigate. Because of the difficulty in receiving a fair decision from VA, we at VAWatchdog have recognized that veterans who have even the simplest claims can no longer rely on a fair decision. Every veteran should prepare to have expert help as they develop their claim. This includes legal representation by a VA accredited attorney as well as expert opinions from highly skilled and well qualified physicians. There is a difference in the IME and the IMO. The IME requires your physical presence in front of the examining physician. IMO Letters are based on the opinion of the physician after he has thoroughly reviewed your records. It is our opinion that the IMO may be the better choice in most cases. To write an acceptable IMO is not a simple task. The physician must first understand the law that applies to the claim. The physician must know the details of how disabling conditions may affect the overall quality of life of the veteran patient. Disability law is not something that most physicians are trained in. Having said that, VAWatchdog currently recommends only two physicians for IME/IMO work. Each of these doctors is expert in the arena of disability medicine. We urge veterans to review their claims with one of these physicians and to seek the help of an attorney Dr. David Anaise is a physician as well as having a license to practice veterans law. In interviews with Dr. Anaise we’ve asked and learned much about him. In discussions with Dr. Anaise he’s told us: “In addition to being a lawyer, I am a surgeon with almost thirty years of medical experience. I was Clinical Associate Professor of Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook. I served as President of the New York Transplantation Society and as Assistant Editor of Transplantation Proceedings. I have authored three book chapters, three patents and 106 research papers published in peer reviewed medical journals. My background in medicine and research makes me well qualified to thoroughly review and present your disability case. I obtain, study and analyze all your medical records and perform independent medical research relevant to the issues of your case. I then present an analysis presenting your medical history in a way that best supports your claim. The submission all the medical report which does not contain an actual physical examination or even the submission of a medical treatises requires the board to address the reports or the medical treatises. In a decision rendered by Judge Bartley In Bowers v Shinseki NO. 11-3022 Judge Bartley was critical of the BVA’s failure to address a medical treatises provided by the veteran. The BVA held that such report was merely laypersons opinion. Judge Bartley held, ‘As a layperson, the Veteran is not competent generally to render a probative opinion on a medical matter. Mr. Bowers, however, was not offering his own subjective opinion as to the growth rate of gallstones; he was repeating the data reported in professional medical treatises he submitted. Certainly, a layperson is competent to report information provided by a medical professional. Cf. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir.2007) (holding that a veteran is competent to repeat a medical diagnosis and report observable symptoms). In labeling the veteran’s report of the growth rate of gallstones as incompetent lay opinion, the Board avoided addressing the substance of the medical treatise evidence Mr. Bowers submitted, just as the Board failed to address those treatises directly. Thus, the Board’s failure to address the medical treatise evidence that was favorable to Mr.Bowers was not harmless. See Sanders and Caluza, both supra. As such, remand is warranted”

The usefulness of IMO Letters to establish rating for sleep apnea secondary to PTSD 

In a recent decision by the BVA (FEB 2 8 2014 DOCKET NO. 11-09 193) the board reiterated the importance of IMO Letters supported by medical literature in establishing service-connected disability for sleep apnea secondary to PTSD the board held: “The Veteran had a VA examination in October 2009. The Veteran reported sleep apnea with an onset two to three months earlier. The VA examiner opined that, per medical literature review, sleep apnea is not caused by or aggravated by the Veteran’s PTSD. The VA examiner stated that the basis of the opinion was the review of medical literature. The literature was not specified. At the Board hearing in March 2012, the Veteran testified that his therapist has told him that PTSD aggravates sleep apnea because he has nightmares and dreams in his sleep. The Veteran testified that he has anxiety attacks in his sleep that keep him from catching his breath. The Veteran testified that he has used a CPAP machine for about four years. In this case, there is positive medical evidence which links the Veteran’s current sleep apnea to service-connected PTSD via aggravation. The most probative opinion is that of Dr. T which not only provided a link between the Veteran’s PTSD and sleep apnea (by aggravation) but also was supported by submitted medical literature. Despite the negative VA opinion, in light of the positive medical opinions from the private psychologist, the Board finds the evidence is at least in equipoise regarding whether the Veteran’s sleep apnea is aggravated by service- connected PTSD. Accordingly, resolving all reasonable doubt in the Veteran’s favor, service connection for sleep apnea is warranted. – Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). ORDER Secondary service connection for sleep apnea is granted

Dr. David Anaise Testimonials

Below are some Dr. David Anaise Testimonials from real people who have used our services. If you have any specific questions about your case, please give us a call at 520-219-7321.

“This [IMO] is absolutely amazing.” – JA (8/31/17)

“The BVA Judge approved my sleep apnea claim and sent it back to the regional office to assign a percentage…Thank you very much.” – PS ( 9/5/17)

 

“Incredible job I’m very happy…Thank you.” –RV ( 9/11/17)
“Your IMO made the difference. I was rated OSA secondary to PTSD. Thank you!” -DF (9/13/17)

 

“The IMO is excellent first class very professional…Thank You Very Much” -AC (9/20/17)

 

“[The IMO] looks outstanding.  Thank you very much.” -RH (9/24/17)

 

“The Sleep Apnea Appeal was superb. The most professional response I have witnessed in all my years.” -FR (10/4/17)

 

“Dr. Anaise, let me begin by thanking you for a wonderful job you did on the nexus letter.  The VA came back to me today and based on the letter you wrote, they raised my disability Rating from 60% to 90%.  I cannot thank you enough for your efforts.”  -DB (10/19/17)

 

“I’m satisfied with this. Thanks again… [Awarded OSA secondary to PTSD, tinnitus]” -RL (10/27/17)

“Thank you…I could not be more pleased with the IMO.” -HP (11/2/17)

 

“Sir, I have looked over the attachment and everything looks good… I would love to write a positive review in how pleased I am with your service. Thank you.” -CE (9/5/17)

 

“Those are both fantastic. Thank you so much.  I am looking forward to receiving them and to fax them to the VA to show the Nexus for my conditions.” -GM (11/16/17)

 

“Yes, we were successful. With great gratitude, a great big THANK YOU to you and your staff.  The VA examiner agreed with your assessment that my service connected chronic sinusitis was at least as likely as not the cause of my OSA.” -JP (12/8/17)

 

 

Yes, my OSA IMO was successful Thank you. I will follow up with you for my next IMO for Cervical DDD soon.” -SC (1/15/18)

 

AC Hartland, MI, 48353

Yes, the IMO report is remarkable. Thank you. I do not have any questions nor concerns regarding the draft you e-mailed me.

IMO Sample

One of my clients  posted this sample IMO letter on Hadit http://www.hadit.com/forums/topic/55854-anyone-use-david-anaise-md-jd/

The sample is redacted to shield his identity and the identity of the treating physicians

 

INDEPENDENT MEDICAL EXPERT (IME) NEXUS-OPINION                19 August 2014

 

To:       Veterans Administration (VA)

 

Re:       CB

 

 

As my attached curriculum vitae indicates [EXHIBIT 1], I am a surgeon with almost thirty years of medical experience.  I was Clinical Associate Professor of Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook.  I served as President of the New York Transplantation Society and as Assistant Editor of Transplantation Proceedings.  I hold three patents.  I have authored three book chapters and 106 research papers published in peer reviewed medical journals.

Mr. CB (“Veteran”) served in the Navy during the Gulf War Era, from December 4, 2002, to April 30, 2012.  The rating decision of July 3, 2013, granted service connection for lumbar spondylolysis L5-S1 with a 10% disability rating.  Service connection for allergic rhinitis and deviated septum were denied; the VA stated that these conditions did not exist during his service.  The veteran also suffers from obstructive sleep apnea.

After reviewing the veteran’s medical records, including service records, I find that the conditions of allergic rhinitis and deviated septum were indeed present during his military service.  I also opine that it is more likely than not that the veteran’s obstructive sleep apnea is secondary to nasal obstruction due to allergic rhinitis and deviated septum.

Review of the medical records

In 2007, while in service, the veteran was prescribed nasal sprays for the treatment of his nasal condition.  A medical record from February 5, 2008, shows that Dr. PC saw the veteran for nasal obstruction.  On exam the veteran was found to have a deviated septum and the nasal turbinates were hypertrophied.  The record also shows that the veteran was treated with nasal drops; the prescription was last filled in May of 2007. [EXHIBIT 2]

In 2009, while still in service, the veteran received care at Makalapa Clinic and the Tripler Army Medical Center (TAMC) in Honolulu, Hawaii.  He was examined by Dr. GN on March 4, 2009, who diagnosed deviated nasal septum and recommended an evaluation at the ENT Clinic.  He was also prescribed Nasonex. [EXHIBIT 3]

On March 11, 2009, the veteran was seen at the Ear, Nose and Throat Clinic at TAMC by Dr. MR for deviated septum.  The veteran complained of a long history of difficulty breathing due to nasal obstruction, worse on the right; with complaints of sneezing, watery rhinorrhea, itchy eyes and palate.  The ENT physician stated that the veteran has clear symptomatology of allergic rhinitis and a deviated septum to the right.  He recommended medical management for two months, and if the nasal obstruction persisted then septoplasty/turbinoplasty would  be considered. [EXHIBIT 4]

On November 2, 2009, the veteran was seen by Dr. ND for allergy testing.  Dr. Duff noted that the veteran was scheduled for a septo/turbinoplasty.  On examination, he found the nasal septum deviated to the right with a spur on the left floor, and pale, swollen and edematous nasal mucosa. [EXHIBIT 5]

On March 9, 2012, the veteran was seen for a severe case of allergic rhinitis, sinus pain, cough, congestion, and nasal drainage. [EXHIBIT 6]

The veteran’s military service separation physical on April 5, 2012, shows that he again complained of problems with breathing and allergies, “had septoplasty but c/o recurrent sinus pain and difficulty breathing secondary to obstruction. [EXHIBIT 7]

Veteran underwent a sleep study on June 12, 2014, by Dr. SP  who is Board Certified in Pulmonary Critical Care and Sleep Medicine.  The polysomnography report revealed mild snoring, a total of one obstructive apnea and 37 hypopneas.  The apneic event was 20.9 seconds in duration and the longest hypopnea was 30.5 seconds in duration.  The lowest oxygen desaturation was 92%.  These findings indicate a moderate form of obstructive sleep apnea.  CPAP was initiated at a pressure of 4 cm and titrated up to 10 cm where improvement was noted.  The veteran was also found to have an abnormal sleep architecture characterized by reduced sleep efficiency, reduced sleep latency, increased stage R latency, reduced amount of stage R sleep, and sleep fragmentation.  Treatment recommendations included BPAP therapy with 10/6 cm water. [EXHIBIT 8]

Review of the medical literature

Conceptually, the upper airway  is a compliant tube and, therefore, is subject to collapse.[i] [EXHIBIT 9]  OSA is caused by soft tissue collapse in the pharynx.  Transmural pressure is the difference between intraluminal pressure and the surrounding tissue pressure.  If transmural pressure decreases, the cross-sectional area of the pharynx decreases.  If this pressure passes a critical point, pharyngeal closing pressure is reached.  Exceeding pharyngeal critical pressure (Pcrit) causes a juggernaut of tissues collapsing inward.  The airway is obstructed.  Until forces change transmural pressure to a net tissue force that is less than Pcrit, the airway remains obstructed.  OSA duration is equal to the time that Pcrit is exceeded.

The Bernoulli effect plays an important dynamic role in OSA pathophysiology.  In accordance with this effect, airflow velocity increases at the site of stricture in the airway.  As airway velocity increases, pressure on the lateral wall decreases.  If the transmural closing pressure is reached, the airway collapses.  The Bernoulli effect is exaggerated in areas where the airway is most compliant.  Loads on the pharyngeal walls increase adherence and, hence, increase the likelihood of collapse.  This effect helps to partially explain why obese patients, and particularly those with fat deposition in the neck, are most likely to have OSA.[ii]  [EXHIBIT 10]

Given this information, it is abundantly clear that even a small reduction in a diameter of the upper airway will cause a collapse of the upper airway during sleep.

The effect of nasal breathing on sleep apnea was studied by Fitzpatrick et al., Effect of nasal or oral breathing route on upper airway resistance during sleep. [EXHIBIT 11] The author reports that healthy subjects with normal nasal resistance breathe almost exclusively through the nose during sleep.  The researchers studied the resistance to the upper airway through either nasal or oral breathing and found that upper airway resistance during sleep and the propensity to obstructive sleep apnea are significantly lower while breathing nasally rather than orally.  Nasal obstruction during sleep results in mouth opening and mouth opening has been shown to increase the propensity to upper airway collapse.  It has been shown that jaw opening is associated with posterior movement of the angle of the jaw, thus compromising the oropharyngeal airway diameter.  This is caused by shortening of the upper airway dilator muscles located between the mandible and the hyoid bone.  In addition, jaw opening profoundly affects the diameter of the retroglossal airway.  The author has shown that there are two distinct sites of airway obstruction during sleep with oral breathing , when nasal breathing is not efficient.

Conclusion

It is clear from the veteran’s service records that his medical conditions of deviated nasal septum and allergic rhinitis existed while he was in service.  After review of the pertinent medical literature, I opine that the veteran’s obstructive sleep apnea is secondary to nasal obstruction due to allergic rhinitis and deviated septum.

Sincerely,

 

David Anaise, JD, MD

Attorney at Law

 

DA /scb

 

Enclosures:      EXHIBITS: (see attached list of exhibits

[i] Patil SP,  Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest. Jul 2007;132(1):325-37. [Medline]. [Full Text].

 

[ii] Schwab RJ, Pasirstein M, Pierson R, Mackley A, Hachadoorian R, Arens R, et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med. Sep 1 2003;168(5):522-30. [Medline].

 

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Veteran Disability Total Unemployability , TDIU

Legal Help for Veterans

What is Total Unemployability

For a veteran to prevail on a claim based on total unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the particular Veteran is capable
of performing the physical and mental acts required by employment, not whether that Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 3 61, 363
(1993). It is also the policy of the VA, however, that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b).
The VA defines un-employability as follows [40 FR 42536, Sept. 15, 1975, as amended at 43 FR 45349, Oct. 2, 1978]:
“A veteran may be considered as unemployable upon termination of employment which was provided on account of disability, or in which special consideration was given on account of the same, when it is satisfactorily shown that he or she is unable to secure further employment. … However, consideration is to be given to the circumstances of employment in individual claims, and, if the employment was only occasional, intermittent, try out or unsuccessful, or eventually terminated on account of the disability, present unemployability may be attributed to the static disability.”

 

TDIU Requirement Veteran Be Unable to Secure Substantially Gainful Occupation

The VA has defined substantially gainful occupation in its Adjudication Procedures Manual (Manual M21-1MR, Part VI, subpart ii, 2F.24.d) as that which is ordinarily
followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides. Marginal
employment is not considered substantially gainful employment. Marginal employment is defined as earned annual income that does not exceed the poverty threshold for
one person as established by the U.S. Department of Commerce, Bureau of the Census. Under the current poverty threshold established by the Bureau of the Census,
marginal income for the year 2010 is $11,334.00.

In Faust v. West, (13 Vet. App. 342, 356 (2000), the Court adopted a definition of a substantially gainful occupation. The Court concluded that a substantially
gainful occupation, is [an occupation] that provides [the veteran with an] annual income that exceeds the poverty threshold for one person, irrespective of the
number of hours or days that the veteran actually works.

In Roberson v. Principi, (251 F.3d 1378, 1385 (Fed. Cir. 2001), the Federal Circuit further defined that the term SGA is flexible. Although the term SGA may not set
a clear numerical standard for determining TDIU, it does indicate an amount less than 100 percent. Veteran, because of service-connected disability, is incapable of
performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. “[T]he BVA may not reject [a
veteran’s] claim without producing evidence, as distinguished from mere conjecture, that the veteran can perform work that would produce sufficient income to be
other than marginal’.” Bowling v. Principi, 15 Vet.App. 1, 9 (2001) (emphasis in text) quoting Beaty v. Brown, 6 Vet.App. 532, 539 (1994) citing see also James v.
Brown, 7 Vet.App. 495, 497 (1995) (“Board ‘was not convinced that there were not some jobs he could do’ but no evidence supported that conclusion”).

The VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded, by reason of his service-
connected disabilities, from obtaining and maintaining any form of gainful employment consistent with education and occupational experience.

Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disabilities are so
severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least
60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability
ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a).

In a pertinent precedent opinion, the VA General Counsel concluded that the controlling VA regulations generally provide that Veterans who, in light of their
individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability
shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a
subjective standard. It was also determined that “unemployability” is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC
75-91 (O.G.C. Prec. 75-91); 57 Fed. Reg. 2,317 (1992).
The Board further observes that being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. “While the term
‘substantially gainful occupation’ may not set a clear numerical standard for determining TDIU, it does indicate an amount less than 100 percent.” Roberson v.
Principi, 251 F.3d 1378 (Fed Cir. 2001).
In discussing the unemployability criteria, the United States Court of Appeals for Veterans Claims, in Moore v. Derwinski, 1 Vet. App. 83 (1991), indicated, in
essence, that the unemployability question, that is, the ability or inability to engage in substantial gainful activity, had to be looked at in a practical manner,
and that the thrust was whether a particular job was realistically within the capabilities, both physical and mental, of the veteran involved.

Consideration of Educational and Occupational History

In evaluating a veteran’s employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a
conclusion, but not to his age or impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.19. Once a Veteran is found to have 60% service
connected disability (or 40%/70%) in step one of the analysis, the VA analyzes the veteran’s educational and occupational history to determine whether his service-
connected disabilities preclude him from securing or following substantially gainful employment (activity) (SGA).

In Beaty v. Brown, 6 Vet. App. 532, 537 (1994), the Court held that to determine whether service connected disability precludes SGA, a general medical examination is
to be scheduled in which the examiner is requested to provide an opinion as to whether or not it is at least as likely as not that the veteran’s service-connected
disability or combined disabilities render him or her unable to secure and maintain SGA, to include describing the disabilities’ functional impairment and how that
impairment impacts on physical and sedentary employment. See also VA Training Letter 10-07 (Sept. 14, 2010).

The Court has stated: “[w]here the veteran submits a claim for a TDIU rating … the BVA may not reject that claim without producing evidence, as distinguished from
mere conjecture, that the veteran can perform work that would produce sufficient income to be other than marginal.” The simple fact that a veteran may be young, or
may be highly educated, or may have been recently employed, or may have had a long work career are not decisive, and standing alone are insufficient justifications
to deny a TDIU claim; Gleicher v. Derwinski, 2 Vet. App. 26 (1992).

 

 

What is the effective date for TDIU

The General Counsel provided a binding opinion in VAOPGCPREC 12-2001 regarding Roberson v. Principi, No. 00-7009, 2001 U.S. App. LEXIS 11008 (Fed. Cir. May 29,
2001), holding the following:

1. Once a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability,
the requirement in 38 C.F.R. 3.155(a) that an informal claim “identify the benefit sought” has been satisfied and the VA must consider whether the veteran is
entitled to total disability based upon individual unemployability (TDIU).

2. A veteran is not required to submit proof that he or she is 100% unemployable in order to establish an inability to maintain a substantially gainful
occupation, as required for a TDIU award pursuant to 38 C.F.R. 3.340(a).
“The VA erroneously demanded that the veteran first file for TDIU and assign the onset date to the date veteran filed for TDIU or filed VA Form 21-8940. This is an
error. When a veteran files an original claim for evaluation of a disability or a claim for an increase in the evaluation of a disability that has already been
rated by the VA, the claimant is generally presumed to be seeking the highest benefit allowable. (See AB v. Brown, 6 Vet. App. 35, 38 (1983); see also Roberson v.
Principi, 251 F.3d 1378, 1383 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009); Norris v. West, 12 Vet. App. 413, 421 (1999). If either claim includes
facts that indicate that the veteran is unemployable, the VA is obligated to consider and adjudicate a TDIU claim.”

In Servello v. Derwinski, 3 Vet. App. 196 (1992), the court held that the existence of an inferred claim for TDIU might have entitled the veteran to an earlier
effective date because under 38 U.S.C.S. 5110(b)(2), the effective date of an award of increased compensation shall be the earliest date as of which it is
ascertainable that an increase in disability occurred if the application is received within one year from such date. The court reasoned that because under 38 C.F.R.
3.155(a), the VA was required to, but did not, forward to the veteran a TDIU application form, the one-year filing period for such application did not begin to run.
Thus, as a matter of law, the inferred claim submitted prior to the date of a formal TDIU application must be accepted as the date of claim for effective date
purposes.
In Collier v. Derwinski, 2 Vet. App. 247, 251 (1992), the Court held the VA was obliged to consider issue of entitlement to TDIU benefits despite the veteran’s not
having filed the specific TDIU application form because he has continually stated that he is unable to work due to his schizophrenia. Roberson, 251 F.3d at 1384;
Norris, 12 Vet. App. at 421

Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the rating agency and the Board has a duty to investigate Veteran’s entitlement to TDIU.

 

 

Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the rating agency and the Board has a duty to investigate Veteran’s entitlement to TDIU. In Rice v. Shinseki,
22 Vet. App. 447 (2009), the Court made it abundantly clear that the Veteran Administration has a duty to investigate the eligibility of a veteran for TDIU when the
veteran requests a higher rating which will entitle him to schedular unemployability and the records indicate evidence of unemployability. The Court stated:
“It is clear from our jurisprudence that an initial claim for benefits for a particular disability might also include an assertion of entitlement to TDIU based on
that disability (either overtly stated or implied by a fair reading of the claim or of the evidence of record)( emphasis added) ….The Federal Circuit’s recent
decision in Comer v. Peake contains language consistent with this analysis: “A claim to TDIU benefits is not a free-standing claim that must be pled with
specificity; it is implicitly raised whenever a pro se veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating.” 552
F.3d 1362, 1367 (Fed. Cir. 2009). This statement of the law is consistent with and reiterated the Federal Circuit’s earlier decision in Roberson v. Prinicpi,
involving the assignment of an initial disability rating, which reversed this Court’s holding that Mr. Roberson failed to make “a claim for TDIU” and held that
consideration of TDIU is required once “a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally
submits evidence of unemployability.” 251 F.3d 1378, 1384 (Fed. Cir. 2001); see also Bernklau v. Principi, 291 F.3d 795, 799 (Fed. Cir. 2002) (discussing a request
for TDIU in the context of a claim for increased compensation for an already service-connected disability). Further, this Court has already stated this principal
clearly: “A TDIU rating is not a basis for an award of service connection. Rather, it is merely an alternate way to obtain a total disability rating without being
rated 100% disabled under the Rating Schedule.” Norris v. West, 12 Vet.App. 413, 420-21 (1999).
Considering more closely the facts of Comer, Roberson, Bernklau, and Norris, we hold that a request for TDIU, whether expressly raised by a veteran or reasonably
raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either
as part of the initial adjudication of a claim or as part of a claim for increased compensation, where the disability upon which entitlement to TDIU is based has
already been found to be service connected.”

 

 

The VA may not deny unemployability based solely on the failure of the veteran to submit Form 21-8940.

The VA often defends its decision not to consider unemployability based on the failure of the veteran to submit Form 21-8940.
First of all, in doing so the Board violated its own policy as clearly expressed in the manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section F, which
states: “Note: Although a VA Form 21-8940 can be an important development tool, it is not required to render a decision in an IU claim.”
Secondly, the Court in Rice already stated that Form 21-8940 is only one of several ways Veteran can request TDIU:
“The Court holds that a request for TDIU is best understood as part of an initial claim for VA disability compensation based on the individual effect of the
veteran’s underlying disability or disabilities or as a particular type of claim for increased compensation. This is not to say that a claimant cannot submit a
request for TDIU at any time, whether on a VA Form 21-8940 or in any other manner (emphasis added). Submission of a request for TDIU does not change the essential
character of an assertion of entitlement to TDIU as a part of either an initial claim or a claim for increase.”

Thirdly, pursuant to 38 C.F.R. § 4.16(a), See also Beaty v. Brown, 6 Vet.App. 532, 537 (1994):

“The Board “may not reject [an application for TDIU] without producing evidence, as distinguished from mere conjecture, that the veteran can perform work that would
produce sufficient income to be other than marginal.”

The manual further instructs the rating agency to be more vigilant where the veteran, (2-F-9):
“Development to produce the evidence necessary to establish the degree to which SC disability has impaired the Veteran’s ability to engage in self-employment must
generally be more extensive than development in cases in which the Veteran worked for others.
When determining entitlement of self-employed individuals to increased compensation based on IU, consider the relationship between the frequency and the type of
service performed by the Veteran for his/her business and the Veteran’s net and gross earnings for the past 12 months.

Consider facts of the case, such as

• low gross earnings that support a finding of marginal employment, especially when the amount of time lost from work due to SC disablement is taken into
account, or
• high gross earnings that indicate the Veteran is capable of engaging in a substantially gainful occupation.

If the information on VA Form 21-4192 only states that the Veteran retired, then request additional information as to whether the Veteran’s retirement was by reason
of disability. If so, ask the employer to identify the nature of the disability for which the Veteran was retired.”

While we believe that VA Form 20-8940 is not mandatory, and clearly should not be the basis for denial of Veteran’s right to benefits, we urge you to enclose the
form with your appeal

 

 

 

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Expediting VA Claims – Can it be done?

If you’re interested in expediting VA claims, the short answer is unfortunately that it cannot be done. The VA has a rather rigid system of first-come first-served, and will not allow an attorney to push your case ahead of someone else’s case. Hiring an attorney, however, can speed up your case significantly by simply avoiding mistakes veterans make in representing themselves.

How the VA system works and how I interact with the system

I would first like to explain how the VA system works and how I interact with the system.

Upon taking on representation, I immediately send the VA a Notice of Disagreement (NOD) and a request for your claim file. Unfortunately, through a process called Freedom of Information Act, it generally takes 6-12 months for the claim file to arrive in our office. Thus, in addition to our efforts, you may want to try and obtain the claim file from your regional office on your own, as sometimes we see that clients receive their claim file faster. Once the claim file is received, I summarize its contents and compose an appeal brief. The appeal brief will be sent to the DRO (Decision Review Officer) or BVA with exhibits. This brief will be sent only when the RO or BVA informs us that they are ready to review your case.

The DRO process

A few months after filing the NOD, the regional office will send us an Appeals Election Form asking us to select the traditional appeals process or the DRO (Decision Review Officer). We will file the Appeals Election Form requesting the DRO process. The DRO is a senior officer at the regional office; he will review your case and has the power to award benefits. Prior to the DRO making any decision in your case, he will either offer you a hearing or ask whether you have any additional information to provide before he makes the decision. This is the only time I can intervene in your case. There is no reason to send an appeal brief to the VA until the regional office informs us that they are ready to review your file. An appeal brief sent uninvited will simply linger in a box with the claim file, or worse get lost. I am committed to review the contents of your claim file, draft, and file an appeal brief once the DRO announces that they are ready to review your file, either by a hearing or on the record. At that time the appeal brief will be sent to the regional office and a copy will be provided to you, so that you can bring a copy to your hearing.

The SOC

After the DRO makes a decision a Statement of the Case (SOC) is issued. The rules require that Form 9, Appeal to the Board of Veterans’ Appeals, be filed within 60 days from the date of the SOC. Once the Form 9 is accepted, the BVA does not begin to work on your case, rather it waits for the regional office to certify the case to the BVA. The BVA is poorly staffed and cases are trickled to the BVA from the regional office. It will be 3 to 5 years before your case will be heard by the BVA. By law the BVA must contact us 90 days before they make any decision. I am committed to provide the BVA with a thorough brief raising all medical and legal issues prior to such a hearing. Again there is no reason to send a brief earlier as it will not be reviewed by the BVA and most likely will get lost.

Waive Jurisdiction

There is strong data to suggest that waiving the BVA hearing, and asking the BVA to accept jurisdiction and make a decision based on the written brief may expedite your case and could shave two years off your wait time.

Based upon the hearing choice that you select, there are different tracks that the claim will follow both at the RO and at the BVA levels. If you request no hearing, the case will be prepared for transfer to the BVA and no further development will occur at the RO level. The RO then prepares a VA Form 8, Certification of Appeal, and sends you a 90 day letter, which indicates that the case is being transferred to the BVA. The letter informs you that you have 90 days to submit any additional evidence or arguments. This is when I file my appeal brief. Many claimants defeat this fast track and submit additional claims or evidence to the RO. The case, instead of progressing to the BVA, ends up lingering in the RO for additional development and the issuance of a Supplemental Statement of the Case (SSOC).

At the BVA

Shortly after the filing of the Form 9, the RO typically sends a letter to you that acknowledges the Travel Board hearing request, but also attempts to persuade you to request a different mode of BVA review. This letter explains that it could be months or years until a Travel Board hearing is scheduled, owing to the backlog of requests and the infrequency of the hearings. The letter advises you that you are on the waiting list for a Travel Board hearing. In 2009 the wait time was 771 days.

The average length of time between filing the appeal and the Board’s disposition was 886 days.

We can definitely shave two years off the waiting time by asking the BVA to rule based on the written appeal and avoid remand to the RO.

Source: Annual Report of the Chairman, Board of Veterans’ Appeals, Fiscal Year 2010

p. 19. http://www.bva.va.gov/docs/Chairmans_Annual_Rpts/BVA2010AR.pdf

Time Interval	Responsible Party	Processing Time
Notice of Disagreement Receipt to Statement of the Case	Regional Office	243 days
Statement of the Case Issuance to Substantive Appeal Receipt	Claimant	42 days
Substantive Appeal Receipt to Certification of Appeal to BVA	Regional Office	609 days
Receipt of Certified Appeal to Issuance of BVA Decision	BVA	212 days
Average Remand Time Factor	Regional Office	493 days

Time Interval	Type of Hearing	Average Elapsed
Substantive Appeal Receipt to Date of Hearing	Travel Board	743 days
Substantive Appeal Receipt to Date of Hearing	Videoconference	678 days
Substantive Appeal Receipt to Date of Hearing	Central Office (DC)	771 days

What Can we do to expedite your case

I want to be clear that nor I, nor any other lawyer, can expedite your case. The VA clearly works on a first-come first-served basis and will not tolerate interference by a lawyer.

The most effective way to get communication from the VA is by recruiting your local Congressperson’s office to help you. By law the VA must respond to inquiries from members of Congress; each member of Congress has an officer with primary responsibilities to the constituents.  The VA does grant some leverage to veterans with exceptional needs and if you meet these criteria your congressperson can petition the VA on your behalf.

There are certain things you can do to expedite your case:

Do not assume that the claim file contains the current medical information. Please go to your local VA and obtain the last two years of your medical records and send them to me.

Write a short narrative describing the major issues you are appealing and what evidence there is that these issues are service-connected.

Focus on no more than three claims which are best grounded by facts and have the potential for the highest rating. As discussed in more detail in another article entitled What is the VA Disability Rating System service-connected disability of 60% for one condition and 40% for another condition do not result in 100% disability, but rather 76%.  Go to this site to calculate  your combined rating or  You may want to invest $0.99 in a phone app called “vetcalc” which can do the math for you. As your combined rating reaches 90%, it is extremely difficult to add new disabilities that will raise your combined rating. You need an additional 60% disability rating to reach 96% which will get you the 100% disability rating; anything below it will simply roll back to 90%. I have seen strong cases of veterans with 90% disability who file for TDIU while also attempting to add another disability of 10%. The VA will often ignore the major claim for TDIU and instead will schedule you for a C&P for the additional disability; after three years they may actually grant you 10% disability which will roll back to 90.

Nothing in the law prevents you from filing a new claim in the future. If you have well controlled hypertension but later on develop a stroke, you can always file a new claim at a later date.

In conclusion, the permissive nature of the Veterans’ Administration disability process, which is very different from the rules that apply to legal procedures and Social Security disability may actually work against you. The VA seems to turn your case back and forth between the regional office and the board and any time new medical information is provided or a new claim is added the case spins out of control.  I strongly recommend that you pursue a strategy of narrowing down the issues to those that will most likely be approved and most likely generate the highest rating.  If the claim is at the BVA, I shall provide the BVA with a detailed legal brief which includes the legal issues central to your case.  I also attach exhibits from your large case file to facilitate review by the board lawyers.  I can also attach a deposition of your testimony.  To speed up your case, I recommend that we waive the hearing and focus on delivering to the BVA the most complete record.  Once these measures are in place, I believe that we can shave at least two years off from the very long time frame needed to secure a successful award.

Lawyer Representation before the Court of Appeals for Veterans CAVC

Recent statistics show that only 17% to 28% of cases are approved at the Board of Veterans’ Appeals (BVA). Fortunately, the U.S. Court of Appeals for Veterans’ Claims (CAVC) reverses the majority of the adverse BVA decisions. Between 1995 -2006, the CAVC heard 18,000 cases in which the claimants had been denied benefits at the BVA level. In almost 80% of the cases, the CAVC either reversed the BVA decision or remanded it for re-adjudication, finding at least one legal error in the BVA decisions. Thus, it is essential that the veteran consider from the outset whether his claim can be heard by the CAVC. Only members of the CAVC Bar can represent Claimants before the Court. Consider this carefully when choosing a veteran appeals lawyer.

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Obstructive Sleep Apnea

 

 

 

 

 

 

 

 

 

 

What is Sleep Apnea

 

Obstructive sleep apnea (OSA) is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep.  These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.  Generally, symptoms of OSA begin insidiously and are often present for years before the patient is referred for evaluation.

Nocturnal symptoms may include the following: Snoring, usually loud, habitual, and bothersome to others Witnessed apneas, which often interrupt the snoring and end with a snort Insomnia; restless sleep, with patients often experiencing frequent arousals and tossing or turning during the night

 

What are the symptoms of Sleep Apnea 

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Understanding Knee Injury Disability Rating

Knee injury is very common among servicemen.  The injury may be slight, but years later, many veterans develop severe knee arthritis attributed to their initial service injury.  Many veterans are so disabled by their knee arthritis that they are unable to work.  Regrettably, the rating for knee disability are outdated and have not been updated for many years.  As a result, regional offices around the country provide rating of only 10% to 20%.  Many veterans with knee disability are unable to maintain gainful employment, and yet they cannot apply for unemployability because their disabling condition is rated as only 20%.

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