Sleep apnea secondary to allergic rhinitis nexus letter

Claiming Sinusitis/Rhinitis & Sleep Apnea (OSA)

Claiming Sinusitis/Rhinitis & Sleep Apnea (OSA)

Jun 14, 2014#12014-06-15T01:00

Looking for some opinions on how I might strengthen my claim for Allergic Rhinitis, Chronic Sinusitis, and OSA.  My SMR is fairly well documented for sinus related issues including congestion, infection, etc...  I'm fairly certain I have that one locked in via direct connection.

I'm diagnosed with OSA w/CPAP and my ENT doctor provided the below Nexus letter.  I'm looking claiming OSA DIRECTLY based on it being undiagnosed but present while in service AND SECONDARY to the Rhinitis/Sinusitis mentioned above.  My SMR does not have any sleep issues mentioned, however they do document Bruxism, TMJ, and Hypertension (I'm rated for TMJ & HTN), conditions which studies have shown to be linked to OSA.    I've also submitted a buddy and a spousal letter which describes my snoring, occasional gasping/snorting during sleep, and waking up during the night to clear my nose/throat:

I wish I had gone to the military docs about my sleep problems, but back when I was in, snoring and being tired wasn't a medical issue, it was just a accepted. Now I'm being treated for it and am looking to claim it as it all started while in service.

Any thoughts on what else I can do that might strengthen this claim?  I've read about many denials online here, but no successes from anyone with circumstances similar to mine.  All the successful OSA claims seem to come from folks with documented in-service sleep issues.  I think directly linking my OSA might be tough (even with my ENT doc's letter), but I'm hopeful that also claiming it secondary to my sinus/TMJ issues will secure a successful claim.

Jun 14, 2014#22014-06-15T03:44

for sinusitis make sure you have it documented you have taken antibiotics for over 2 weeks and document every occurrence. Going thru this now myself. Your letter should also address how the disability affects you day to day. Letter from your supervisor would help.

Jun 15, 2014#32014-06-15T13:10

Thanks for the heads up. On the severity of the sinusitis, how is the below interpreted?

One or two incapacitating episodes per year of sinusitis requiring
prolonged (lasting four to six weeks) antibiotic treatment, or; three
to six non-incapacitating episodes per year of sinusitis characterized
by headaches, pain, and purulent discharge or crusting ..................................... 10%

Does that mean I needed to be bedridden for 4-6 weeks, or simply had to take my antibiotics? I don't know if I've every had to take amoxicillinamoxicillin longer than 2-3 weeks. I certainly have well over 3 sinus episodes a year, to the point where I'm taking a daily corticosteroid, which helps a little.

Does the Allergic Rhinitis and Sinusitis get rated separately? It would see they are closely related (as in the congestion from the AR leads to the Sinusitis).  I see a separate rating for AR, but will the VA grant both, or just one or the other?

Jun 15, 2014#42014-06-15T13:40

Being out of the service for over ten years is going to be hard to overcome but the letter is pretty powerful.  Good luck going forwards.

A Co. 2nd/2nd
      1st Infantry
      11/66-11/67     

Jun 15, 2014#52014-06-15T17:29

BROVET wrote:

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Being out of the service for over ten years is going to be hard to overcome but the letter is pretty powerful.  Good luck going forwards.

Thank Brovet.  I know the time difference will be the biggest hurdle.  Wished I'd know about OSA while in service, or even right after I got out.  That being said, I'm trying to make the best of the situation and hope it meets the threshold.  It's not like I'm trying to make chicken-salad out of chicken-poop.  More like chicken-salad out of turkey leftovers.  If I succeed, hopefully this will open the door for others who have been discouraged to come forward with similarly circumstanced claims.

UPDATE - Sleep Apnea awarded w/out In-Service Treatment

Aug 08, 2015#62015-08-08T15:40

UPDATE - My claims for Allergic Rhinitis, Sinusitis, and OSA were initially denied. The sinus and allergies were denied due to lack of chronicity, and the OSA simply stated there were no history of treatment for the condition while in service. It was as if the Rater didn't even read the medical opinion.

So, I kept getting treatment, then resubmitted to Reopen my claim. While the claim was in-process, I submitted an appeal for the Allergic Rhinitis & Sinusitis before my 1 year mark. Because of the appeal, those two conditions were removed from my reopen claim. All that was left was the OSA, which I figured would be denied since part of it hinged on being secondary to the other two issues.

Much to my surprise, the claim completed, and I was awarded 50% SC for the OSA with an effective date back to 2013 when I originally filed for it. I'm still awaiting for a DRO decision on my Allergic Rhinitis and Sinusitis.  I'm thinking during the QRT on the reopen, they saw something that made them SC the OSA to back when it was first claimed.

I'm still waiting to receive the official BBE, but I assume the OSA is direct service connection, as my other respiratory issues are still under appeal. When viewing the rating in eBenefits, I can't tell if a condition is secondary or not. It just shows the percentage and effective date.

Thanks for all the advice and encouragement. I know many of our brethren are in similar circumstances where they probably suffered from OSA while in service, but never sought treatment until after they got out.  

Aug 08, 2015#72015-08-08T15:55

BROVET wrote:

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Being out of the service for over ten years is going to be hard to overcome but the letter is pretty powerful.  Good luck going forwards.
 

Congrats on the award while bitter sweet.

Just a curious question as I have SMR that shows MRI's report of rather marked changes of chronic sinusitis involving the ethomidal and bilateral maxillary sinuses and current congestion and sleep issues.

How come we as veterans are held to overcoming time frames after service, while the VA is at times the one's who have delayed continued care? A PCP can only send in so many directions at once.

Aug 08, 2015#82015-08-08T22:51

I think the time since service issue often becomes a hurdle because even though you may have issues in service, we get dinged for "chronicity" post service if we don't keep getting "treatment".

For allergies & sinus issues, unless you have great insurance, you don't always have the luxury to see the doctor every time your nose clogs.  Having been in service long enough with "free" medical, you learn that the medical professionals often just give you OTC meds to handle the allergies and sinus congestion.  Occasionally, they'll throw in an antibiotic if the sinuses become infected.  So post-service when seeking medical treatment hits you for a $20-$30 copay everytime, you just opt to buy about $5-$10 worth of Over-The-Counter meds and self-treat.

Self treating post-service hurts a lot of vets (including myself) because even though the issues you had in-service continued, now you don't have the paper trail to prove it once you decide to file a claim.  Unfortunately, that's just how the system works.

I'm actually not so bitter sweet about the 50% OSA. It was a nice surprise to see it get awarded without having to jump through further hoops.  Just this week I had septoplasty surgery, so I may have a new sleep study done in a few months and find that I'm cured.  If so, I'll be glad to give up the 50% rating to breathe like a normal human and get off of the CPAP.

Aug 08, 2015#92015-08-09T01:38

Amen to that brother, my wish is that all goes well for you. What do you feel the surgery... fixed? My PT mentioned them grinding away in my face (mmm no thanks, as you know what I mean).

Please send an update on how you are doing.

Aug 08, 2015#102015-08-09T02:08

Preaching to the choir

Hopefully, the surgery gives you some relief. I'm in purgatory as my ENT will not perform the procedure as she states NSC AR/Sinusitis is a precipitating factor of my NSC OSA. I am unable to receive allergy therapy (the shots), because of the risk of acute respiratory failure (beta blockers in combination with the shots). Unlike yourself, I have no evidence that would warrant SC for OSA.

Aug 09, 2015#112015-08-09T19:37

redrollinsrancher wrote:

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Amen to that brother, my wish is that all goes well for you. What do you feel the surgery... fixed? My PT mentioned them grinding away in my face (mmm no thanks, as you know what I mean).

Please send an update on how you are doing.

I had the procedure 4 days ago and was pretty miserable up until today.  I still have these long plastic stints in my nose and it's difficult breathing through my nose.  (Google "Doyle Nasal Splints" and you'll see how big these things are).

I've had to mouth breathe the last 4 days, and can't use my CPAP, so I haven't been getting much sleep.  I'm told that once the stints come out (in 2 more days), I SHOULD be able to breathe better.

Surprisingly enough, I have 3 co-workers who have had the same procedure and they all swear by it.  So I'm hopeful my quality of life improves.  At a minimum, it cures the snoring, my wife's QoL will improve which in turn will affect my QoL as well,.

Sinusitis Nexus letter

Aug 09, 2015#122015-08-09T19:40

Hello, you mentioned an ENT doctor's Nexus letter in your posting, is this something that you could share? I realize that this has been over a year since this positing, but it would help me to get my ENT doctor to write a letter for me.

I have been diagnosed with severe sleep Apnea, but fefore I was to go to my 2nd sleep study to see if I need a CPAP device, I was then diagnosed with Maxillary Sinusitis, so I delayed my sleep study for a month after my Sinus surgery in order to include the sinus issues with my Sleep Apnea claim.

Any help would be appreciated.

Aug 09, 2015#132015-08-09T21:20

I have been retired for 18yrs and I was awarded 50% for sleep apnea secondary to my allergic rhinitis with a deviated septum. Below is the NEXUS letter I used.
The VA called me one day and asked which one of the three items I wanted to use for my secondary for sleep apnea? I told them"allergic rhinitis with a deviated septum".

Date: 9/2/2014

Reference:

To the Department of Veterans Affairs

I have reviewed Mr. Veteran’s military service medical records, NMC San Diego, Ca; medical record, Navcare medical records and his current & passed records with Kaiser Permanente. It is my opinion that “it is more likely than not” that Mr. Veteran’s sleep apnea is secondary and/or proximate to the veterans service connected sinusitis and allergic rhinitis with a deviated septum. I base my opinion on the following items below.
Mr. Veteran has along medical history dating back to September 14, 1977 being diagnosed with allergic rhinitis and chronic sinusitis. Mr. Veteran is currently being seen for his sinus issues. He was diagnosed with a deviated septum on his Veteran Affairs (VA) exam dated 12/17/97, 2 months and 17 days after discharge. Mr. Veteran has had apolysomnography (6/27/11) by Kaiser Permanente prior to him becoming my patient and the results concluded that he was diagnosed with obstructive sleep apnea (OSA).He requires the use of a breathing assistance device such as continuous positive airway pressure (CPAP) machine.
Sleep disruption caused by obstructive sleep apnea can be exacerbated by his sinusitis and allergic rhinitis with a deviated septum. Being undiagnosed at an earlier stage and untreated, Mr. Veteran also has heart palpitations; hypertension (high blood pressure), pre-diabetic and weight gain which sleep studies have linked to sleep apnea. When I became Mr. Veteran’s primary doctor, I changed all his medications he was taking and started him on Losartan 100mg, Atorvastatin 20mg, Omeprazole 20mg, Dulera, Fluticasone Propionate. He was instructed to continue taking aspirin daily and Zyrtec.
It is my opinion that while on active duty, he had all four problems and unfortunately the sleep apnea was diagnosed after retiring from the service. Mr. Veteran’s obstructive sleep apnea is aggravated by his service connected chronic sinusitis and allergic rhinitis with a deviated septum.

Sincerely,

Aug 09, 2015#142015-08-10T02:28

mikeehamm wrote:

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Hello, you mentioned an ENT doctor's Nexus letter in your posting, is this something that you could share? I realize that this has been over a year since this positing, but it would help me to get my ENT doctor to write a letter for me.

I have been diagnosed with severe sleep Apnea, but fefore I was to go to my 2nd sleep study to see if I need a CPAP device, I was then diagnosed with Maxillary Sinusitis, so I delayed my sleep study for a month after my Sinus surgery in order to include the sinus issues with my Sleep Apnea claim.

Any help would be appreciated.

PM for a copy.

Aug 10, 2015#152015-08-10T04:04

I to have been going through this same claim as I had a broken nose from an attack in the service and I've been denied from the BVA then it was remanded back to the BVA from the CAVC and denied again and now it's back at the CAVC. More developements have happened. I to had surgery on my nose but I still have problems with snoring, sleeping, breathing and everything else associated with it. I've had a sleep study done as well. I have some more issues on this but I won't hijack your post and I'll start another one. Glad you got what was needed!!

Incidently I've been on this now 4 years and most of the problem is I've been out for 32 years and so I do know it will be an up hill battle some more. the VA conceded my deviated septum as occured in service with 0% compensability but can't seem to find a Dr who will write the nexus letter, I think we know the VA isn't gonna do it. LOL!!

Aug 10, 2015#162015-08-10T05:47

my experience is i was rated only with 1 sinustis rating, they combined rhinitis and sinustis rating together for 30%.

hope it helps.

bc

Aug 10, 2015#172015-08-10T12:56

bigcountry wrote:

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my experience is i was rated only with 1 sinustis rating, they combined rhinitis and sinustis rating together for 30%.

hope it helps.

bc

Thanks, I was wondering if they would rate those separately, or group it into one rating. Since they all affect the respiratory system, it might be pyramiding to get separate Allergic Rhinitis and Sinusitis ratings.

Grouping the two, if rated on incapacitating episodes, might be better to reach the 30% threshold rather than having two separate 10% ratings.

Aug 21, 2015#182015-08-21T14:55

I am in the same boat as you once were with being diagnosed with sleep apnea after being discharged over 10 years ago. I also use a CPAP machine. I do have a history of allergic rhinitis and sinusitis while in the military, as well as asthma which was exacerbated while I was on active duty. I am just now starting this entire process of filing for benefits. Could you provide your Nexxus letter so I can show my doctor the example?

Aug 21, 2015#192015-08-21T19:51

MyssThang wrote:

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I am in the same boat as you once were with being diagnosed with sleep apnea after being discharged over 10 years ago. I also use a CPAP machine. I do have a history of allergic rhinitis and sinusitis while in the military, as well as asthma which was exacerbated while I was on active duty. I am just now starting this entire process of filing for benefits. Could you provide your Nexxus letter so I can show my doctor the example?

Check your PM.

Aug 21, 2015#202015-08-22T02:05

I filed for a chronic sinus condition when I was ETSing and was denied. They told me it was "most likely just allergies or a slight cold". When I was in the service, the medic would just shrug it off as allergies and tell me to just go get some sinutab or bendryl at the PX cause thats exactly what they'd give me if I went on sick call (and everyone knows, you dont want to be "sick boy" going on sick call 2-3 times a month right).
So, to be short, I did not have a "history of treatment".
Fast forward a dozen years, and a private doctor is treating me for sinusitis. Then in 2011, I started experiancing episodes where if felt like I just wasnt getting enough air whenever i exerted myself (if I was hiking up a hill for work or something). The doctors couldnt explain it, but diagnosed me with asthma in order to proscribe advair (1 year,had no effect) and singulair (6 months,again no effect).
Then in april of this year the VA diagnosed me with OSA, and issued me a CPAP. Tryng to sleep with the CPAP is hell. I wake up with a horribly congested nose and sinus headache almost every morning. I've reopened my old claim from 1993 on the sinus issue, but Im not holding out much hope because the frigging doctor who treated me for sinusitis back in 2004 retired, and the medical facility deletes/throws out all medical information over 7 years old.

Aug 22, 2015#212015-08-22T12:46

NCBILL - if you had allergies in service, you can file for Allergic Rhinitis as well. You mentioned a lack of documentation. Do you have ANY entries in your record of allergies or sinus complaints? If you do, and your are currently experiencing those issues, see if you can have your doctor render an opinion linking AR and Sinusitis to your military service.

Sinusitis..

Aug 22, 2015#222015-08-22T18:07

No, its been over 20 years, but I'm pretty sure I dont have a record of treatment for any respiratory ailment, except maybe the pneumonia I got in AIT.
Our unit medic in our barracks would just tell me to go get some sinutab or benedryl at the PX instead of going on sickcall if my sinus's were bothering me, so thats what I always did.
Even when I went through the outprocessing physical and told them about the chronic sinus problems, they shrugged it off and told me it was probably just allergies or a slight cold. 
When I filed for it in 1993, they denied it then because I had no in service treatment history.
 

Is sleep apnea secondary to allergic rhinitis?

Can I claim sleep apnea secondary to sinusitis?

What conditions are secondary to allergic rhinitis?

What conditions are secondary to sleep apnea?