IMO for sleep apnea

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

Daytime symptoms may include the following: Nonrestorative sleep (ie, “waking up as tired as when they went to bed”) Morning headache, dry or sore throat Excessive daytime sleepiness that usually begins during quiet activities (eg, reading, watching television); asthe severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving). Patients begin to experience daytime fatigue/tiredness, Cognitive deficits; memory and intellectual impairment (short-term memory, concentration) Decreased vigilance, Morning confusion Personality and mood changes, including depression and anxiety Sexual dysfunction, including impotence and decreased libido Gastroesophageal reflux and Hypertension

 

I snored while I was in service but never complained about it

 

A sleep-related breathing disorder (SRBD) continuum has been described and is supported by research.  OSA can be thought of as occupying a range of this continuum The idea of the SRBD continuum was first described by Elio Lugaresi: “There is a continuum of intermediate clinical conditions between trivial snoring and the most severe forms of OSAS (which we prefer to call heavy snorers disease). This fact should be taken into consideration for any meaningful approach to the clinical problems posed by snoring. Many issues, however, remain unsettled.”

The SRBD continuum suggests that snoring is the initial presenting symptom, and it increases in severity over time and it increases in association with medical disorders that may serve to exacerbate the disorder, such as obesity. Snoring has a constellation of pathophysiological effects.   As the disease progresses, SRBD patients begin to develop increased UA resistance that results in a new hallmark symptom: sleepiness. Sleepiness is caused by increased arousals from sleep.

 

Sleep disorder secondary to PTSD or pain

 

Scientists at the Madigan Army Medical Center have recently studied the incidence of sleep apnea in military personnel    They observed that Sleep disturbances, however, are increasing in frequency and are commonly diagnosed during deployment and when military personnel return from deployment (redeployment).   Recent evidence suggests the increased incidence of sleep disturbances in redeployed military personnel is potentially related to PTSD, depression, anxiety, or mTBI. .

short sleep duration (SSD)  was highly prevalent in the study, with a self-reported sleep duration average of 5.74 h of nightly sleep and 41.8% sleeping 5 h or less per night. This finding is consistent with prior studies of military personnel who habitually report SSD. Compared with civilian reports, these findings are substantially higher than the 9.3% prevalence reported in the adult population in the United States.

Medical comorbidities were frequently identified in military personnel undergoing PSG, 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%).   A potential reason is that insomnia often precedes anxiety and depression, resulting in the referral for sleep evaluation. The relationship of insomnia to PTSD, however, may not be solely as a symptom or a comorbid disorder. Disturbed sleep prior to a traumatic event is a risk factor for the development of PTSD. Persistent insomnia 4 mo after deployment predicts changes in depression and PTSD symptoms. Further, the sleep disturbances of insomnia and nightmares can persist despite appropriate therapy for PTSD

Military personnel with the diagnosis of pain syndromes were more likely to have insomnia. Poor sleep is a recognized symptom in individuals who have medical disorders associated with pain. Previous studies using both questionnaires and PSGs have reported patients with pain have difficulties initiating and maintaining sleep, supporting the association of pain syndromes with insomnia.,   In the study’s  cohort, 24.7% were identified as taking medications for pain.

 

The usefulness of IMO 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 an IMO 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.”

A lawyer and doctor write nexus letters for disabled veterans

anaisedavid.office@gmail.com

520-219-7321

In addition to being a lawyer I am a surgeon with almost thirty years of medical experience. I served as Clinical Associate Professor in Surgery and Attending Surgeon in Transplantation at SUNY at Stony Brook, , New York Assistant Editor, Transplantation Proceedings and President of the New York Transplantation Society.

As a associate professor of surgery I have authored 3 book chapters three patents and 106 research papers published in peer reviewed medical journals. Because of my medical and research background, I believe I am in the best position to study and present your disability case in the best light

Testimonials

Dr. David Anaise Testimonials
Posted on: March 5 2015 / Written by: Dr. David Anaise

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.

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.

I do have a problem with you price, I believe it was too low for the time and expertise that was put into the final draft and exhibits.
By the time you have read this on Wednesday, February 25th, 2015, I would have already mailed another check in the amount of $300.00 through the mail.

I did this for three main reasons. I asked for one medical opinion, you took the time to issue two opinions. You said you needed about two weeks, I believe. The authored paper was done ahead of that estimated time.

S B
Yes. Thank you you can forward hard copy. Would you mind if I make referrals to you. I am very pleased with your professionalism and services.
DC
Everything else looks great. Do you want me to update you regarding my case upon the review of your IMO by the VA?
CBaker 84 on Hadit http://www.hadit.com/forums/topic/55854-anyone-use-david-anaise-md-jd/
Posted 27 August 2014 – 05:41 AM

I recently just got my IMO back from David Anaise. After reviewing everything regarding claims and processing, I’m almost certain that it will be a benefit to me. Ultimately, for the issue I contacted him about, he opined that it was “more likely than not” connected in the manner I suggested and also that it “is due to” my other primary conditions.

One issue that he picked up on is that he knew that the VA denied my two primary conditions, so he also stated that they were present while in service (which they obviously were).

I have attached the IMO ( David Anaise, IMO IME Nexus Letter redacted.pdf 661.71KB 108 downloads) so that other people may see what they should be getting. There were quite a few attachments to this and they have not been included. I also have a 2nd IMO that will be coming from dr. Bash.

Total costs for the IMO was quoted and paid at $1500.00; nothing else was asked for at all and it seems like they do this often on the side. This cost for IMO was also true for Dr. Bash. I had a few other quotes in the realm of $3k-5k dollars. Honestly, this it what I would expect from a medical expert. When I was working with attorneys, expert witnesses were almost $1500 a day, and about 2k-5k dollars to write a report for the case.

My reasoning in getting the IMO was that after having the VA look at the wrong records (cited as 13 years before my birth), denying all my claims except one, and not performing any of the required tests – I felt that my best option was to have an IMO. For a total cost of $3,000, I may or may not have been able provide all the required evidence to prove my claims; I think my claim is also simple (OSA). For others, where their claim is more difficult, more disabling, or far more intricate, I think an IMO could be a blessing. I was also very fortunate that this wasn’t going to put me in a bind financially (Used GI bill $ from school to fund it).

My biggest suggestion: Put as much evidence as you can into it. Submit lay statements, submit medical journal’s in support of your claim, try to find a Dr. to submit a nexus letter, go to the VA and get treatment etc. Do whatever, legally, to tip the scale in your favor.
Pete moderator for Hadit
Posted 29 August 2014 – 05:29 PM
That was a good IMO. Good Luck very impressive credentials by the way

Posted 31 August 2014 – 09:09 PM

Hello all,
I looked at Dr. Anaise’s site and read his bio. He was on the Golan Heights in the ’73 Yom Kippur War in a tank when they basically saved Israel from being overrun by the Russian tanks operated by the Syrians. That got me looking at books about that war and came up with The Heights of Courage. I don’t think the good doctor is mentioned in it as I’ve never read a more personal account of an ongoing battle and would have remembered his name. Of course it was a brigade so…………………. Anyway, you get the point. This guy isn’t someone that got his doctor’s degree and then an attorney’s and that was it. He is one of us and it doesn’t make any difference which war he was in.
Mark Posted 01 September 2014 – 01:35 PM

I spoke with Doctor Anaise over the phone a little while back. Very professional, and pretty much tells it like it is. The $1,500.00 fee is for an IMO for all claimed conditions combined that he finds a nexus for. Not a “per” condition rate, but for the whole thing. Not too bad in the long run. As I mentioned, he seemed very professional and courteous. I’ve thought of using him, but still researching the benefit of obtaining an IME instead, just for the fact that a doctor would actually examine me instead of an IMO records review. I’ve never done either before, outside of an IMO from my personal oncologist, so I want to make sure I spend my money in the right direction for my own personal case.
E-2 Recruit Posted 18 November 2014 – 01:46 PM

I’ve been involved in a 4-year battle with the VA over base of the tongue cancer from Agent Orange exposure in Vietnam. Several months ago, I engaged the services of Dr. David Anaise in Tucson, Arizona. Dr. Anaise is both a medical doctor and attorney. I’ve been very pleased with his efforts and find his fees consistent with a high level of experience and expertise. He wrote an outstanding Independent Medical Opinion (IMO) about the connection between Agent Orange exposure and my cancer. Dr. Anaise has quickly focused on the key elements of my claim. He is a pleasure to work with and knows his stuff.

| IMO nexus

IMO sample Re Sleep Apnea

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].

 

IMO And Nexus Letters For Disabled Veterans

anaisdavid.office@gmail.com
What is Nexus?

There are three steps involved in a claim for service connection according to Caluza v. Brown, 7 Vet. App. 498. First, the veteran must present satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease [38 U.S.C.S. 1154(b)]. 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 (requirement #1) and the precipitating disease, injury, or event that occurred during the period of military service (requirement #2).

What is an IMO?

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 an IMO/ nexus letter

The Institute of Medicine (IOM) was asked by the Veterans’ Disabil¬ity Benefts Commission to study and recommend improvements in the medical evaluation and rating of veterans for the benefts 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 examin¬ing 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 suffciently 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 fscal 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 we do:

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

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

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

4) Perform detailed research of medical literature if there are questions of medical etiology and service connection

What is the cost

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:

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

Samples of my work

For privacy reasons I cannot share with you the reports I provided to my clients.  I can , however  share with you  briefs of cases I  litigated before the Court Of Appeals   ( CAVC ) These cases are listed  in    Representation before the Court of Appeals for Veterans CAVC

The names of the clients have been adducted

The VAWatchdog.org recomendations

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. The IMO is 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 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 an IMO 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