May 1, 2025 • 61 mins
Bethanie Spangenberg, former VA C&P examiner and CEO of Valor 4 Vet, breaks down shocking VA denial patterns and provides strategies for veterans to fight back against illogical denials.
• Copy-pasted medical opinions appearing in denials across different regional offices
• VA examiners citing general risk factors without considering veterans' specific medical conditions
• Cases where non-medical VA staff insert their own medical opinions into denial decisions
• Examples of VA omitting service periods that contain evidence supporting claims
• How the VA repeatedly claims obesity is "a choice" despite service-connected conditions limiting physical activity
• Understanding the growing evidence linking PTSD and sleep apnea despite VA denials
• Absurd case where a widow was denied benefits because her husband "didn't have cancer" when using fentanyl
• Why veterans should carefully review all rating decisions for errors and omissions
Don't give up. Go wherever you need to go to get the proper representation, but get it done. Read your denials carefully, make sure they're really talking about your case and your situation.
Tune in live every Thursday at 7 PM EST and join the conversation! Click here to listen and chat with us.
Visit J Basser's Exposed Vet Productions (Formerly Exposed Vet Radioshow) YouTube page by clicking here.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
J Basser (00:01):
Welcome folks to another episode of Exposed to
that Productions.
My name is John.
They call me Jay Besser.
I'm the host of this show Today.
I have.
Well, let's do the day.
Today is the first day of May2025.
It's a, you know, a littlerainy day, but it's pretty cool.
Here in Kentucky I've got myco-host, mr Ray Cobb.
How you doing, ray?
Ray Cobb (00:20):
I'm doing great.
How are you on this May Day Did?
J Basser (00:23):
you get out and play with the May Day Bulls.
No, no, no, I don't do thingslike that.
To me it's not playing May Day,it's called hobble around the
pole.
You know we got a treat for youguys.
We got a young lady that'squite regular on the show and
we're going to have a bigdiscussion tonight on certain
types of denials that youreceive from the VA.
(00:45):
You know, we thought all weektrying to find a nice fancy name
for this show and we finallyfigured it out.
This is Bethany Spangenberg.
She is the owner, ceo and theHMFIC of Valor for Vet.
Bethanie Spangenberg (01:01):
That's the Highly Mobile Foley
Instructor's Chair.
Oh my gosh, Took you a minuteto come up with that acronym.
How?
J Basser (01:09):
are you doing girl?
Bethanie Spangenberg (01:10):
I'm good.
You know, I'm actually reallyexcited because my seedlings are
sprouting and we've got lots ofrain and I'm hoping that this
summer we're not getting a bigdrought and hopefully I can have
a beautiful garden.
So today's a good day.
J Basser (01:29):
Get them.
Missouri wonders girls, you'llbe fine If you like green beans
stick beans and all kinds ofstuff.
Okay, well, it's awesome.
I know we were going to touchon these denials and I guess
we've been compiling some stuffand we've discussed a few of
them.
You know, in the process ofsetting up the show, and I think
(01:50):
you got a couple of good onesthere that the listeners need to
listen to, because some of thisstuff is it's like I don't know
they're on Mars or something.
I have no idea what they'redoing.
I don't think they do eitherTell you a lot of cases.
Bethanie Spangenberg (02:02):
Yeah, it's actually pretty surprising to
see some of the verbiage in therating decisions and you know,
doing what we do on a regularbasis.
We see a lot of ratingdecisions and we want to see
those.
So then that way we can kind ofrefute you know what their
medical expert is saying versus.
You know what we have in ourreports.
(02:24):
So we see a lot of medicalopinions.
We see a lot of denial letters.
One thing too with me being aformer compensation and pension
examiner, I pick up on a lot ofverbiage that is basically
copied and pasted from examinerto examiner and I know what
(02:45):
that's like to receive an emailfrom your regional office to say
, hey, use this verbiage.
And basically every examiner iscopying, pasting that into
their denial opinion.
And so every case that I havehere today it's hopefully a
learning lesson.
Have here today it's hopefullya learning lesson, something
that can teach veterans, veteranadvocates, and use some of my
(03:11):
frustration into a usefuleducation moment, I guess.
But I've got a whole stack ofthem and I kind of was just
going to randomly pick onebecause hopefully we can get
through them all, but there'squite a bit.
And I'd like to hear somestories from you guys as well,
(03:31):
because it always, you know,telling the stories helps other
veterans to kind of, you know,compare themselves to other
veterans.
So, all right.
One, two, three, four, five,six.
I have six right here.
John, give me a number One.
Two, three, four, five, six.
I have six right here.
John, give me a number Onethrough six.
J Basser (03:50):
See, my favorite number is no, let's not do that,
let's do three.
Bethanie Spangenberg (03:53):
Three, one , two, three, all right.
So one, two, three, four, fiveyeah, I have six, I thought I
had more than that.
So this one this is a case thatwe worked on, that we received,
and this is a rating decisiondated March 28th of 2024.
So a little over a year ago andthis veteran was applying for
(04:18):
sleep apnea and this ratingdecision says that their
previous denial for serviceconnection was confirmed and
continued.
So, in the details of, and ifyou have a rating decision with
you and you want to kind offollow along as we do some of
these, you know, I highlyencourage that, because there's
(04:39):
certain sections of the ratingdecision that, as a medical
examiner, we like to look at.
And when we look at the ratingdecision, we first start with
the dates of service that arerecognized by the VA, because
medical examiners don't gothrough each DD-214 to verify
when your service was.
We're relying on the VA to givethat information to us.
(05:00):
So that's the first thing welook at is the dates of service
us.
So that's the first thing welook at is the dates of service.
And when we jump down to whythe veteran was denied for their
service connection, the VA putwe requested a medical opinion
of the new evidence submittedwith your supplemental claim.
The conditions of sleep apneaand post traumatic stress
(05:20):
disorder are not medicallyrelated.
The obstructive sleep apnea isa separate entity, entirety from
the post traumatic stressdisorder and not medically
related.
The obstructive sleep apnea isa separate entity, entirety from
the post-traumatic stressdisorder and unrelated to it.
A thorough review of medicalliterature failed to demonstrate
a causal relationship.
A nexus has not beenestablished and it's interesting
that I started that.
We started with this onebecause when I was at the VA and
(05:44):
I was a compensation andpension examiner, we would
receive emails of verbiage toadd into the comment section of
our report and sometimes itwould be because new case law
came out, but sometimes inhindsight it was to circumvent
(06:05):
the rating schedule and thisverbiage.
If you've been denied for sleepapnea, you've probably seen
this same verbiage in yourdenial letter, because when they
say that sleep apnea is aseparate entity, entirely from
fill in the blank and unrelatedto it, a thorough review of
medical literature failed todemonstrate a causal
(06:27):
relationship.
That is all copied and pastedand, believe it or not, this was
not intentional.
But another rating decisionthat I have to discuss tonight
has the same verbiage and it'scompletely different areas of
the country.
So that should be a flag.
Whenever you look at yourrating decision, you see that
(06:53):
verbiage in there.
So if we jump down to the bottomsection, where they quote the
medical examiner's opinionfurther, the medical examiner
talks about what sleep apnea isand then it says quote the most
common cause of sleep apnea inadults is obesity, being a male
and advanced age.
Okay, that was the reason whythey denied this veteran.
(07:14):
Now there's no reference tomedical literature associated
with this.
There is no discussion aboutthe veteran's individual case.
And then the second opinionthat was issued was that there
was not a link found between thesleep apnea and the known toxic
(07:36):
exposures, including, but notlimited to, the veterans'
deployments to Kuwait.
A nexus has not beenestablished.
So that's another pattern thatwe're seeing.
They're throwing everythingagainst a toxic exposure-related
activity or a TERA, and a lotof times the veterans aren't
even claiming that way.
(07:57):
So that's an easy way for themto say a denial.
So if we actually look at theveterans' history, remember
there's three things that whythe veteran was denied that the
medical examiner said.
They said well, the riskfactors are obesity, being a
male and advancing age.
So then we pull up theveteran's history and he had a
(08:21):
sleep study done in July of 2019.
At the time of his diagnosis hewas 42 years old, which is not
a risk factor for sleep apnea,and his body mass index was 27,
which is not a risk factor forsleep apnea.
So the only risk factor thatthe CMP examiner identified that
(08:48):
was correct was that he was amale.
And so when we wrote the nexusletter, we said in July of 2019,
when he had this study, theonly conditions that he was
known to have and diagnosed withwas PTSD, vitamin D deficiency.
Those are the only two things.
(09:13):
So then we have to break down.
Okay, why has this veteran, whois not obese, who is not
advancing age, why did hedevelop sleep apnea?
And so for this one, we decidedthat the evidence suggested
that his sleep apnea wassecondary to his PTSD.
And in the bottom section ofour nexus letters this is where
(09:33):
I have the most fun is because Iopen up and I just kind of
hammer out like everything thatwas incorrect and so I put on
there.
You know, the veteran waspreviously denied service
connection.
A previous CMP examinerprovided a negative opinion,
stating that obesity, being maleand older age are the most
common causes of sleep apnea inadults.
However, this veteran does notfit the profile as he is neither
(09:56):
obese nor of advanced age.
The medical opinion lacks adiscussion on this veteran's
specific medical conditions andthe risk factors related to
sleep apnea.
So when you put the medicalopinion side by side, you know
ours has more probative valueand we're just arguing that you
know the VA opinion wasinadequate.
It's insufficient, it's notaccurate, it's not looking at
(10:19):
this veteran's?
Conditions.
I think she's frozen or lockedup.
J Basser (10:25):
You cut out a little bit or is it me cutting out?
Let me get it straightened out.
There she is.
It's lagging a little bit.
Can you hear it, Bethany?
Bethanie Spangenberg (10:46):
I see that .
Yeah, I can hear you.
Now Am I lagging?
J Basser (10:51):
Okay, it's lagging a little bit.
It must have about freezed youup.
I don't know if it's a plug-inproblem or something like that.
I know you got fast enoughinternet.
Sometimes it does that.
(11:13):
We're still set on 720.
Okay, we have folks beentalking about just denials and
some of the crazy stuff theycome up with.
You know, like you don't really.
I mean, you have to have sometype of medical nexus or
(11:35):
information.
Okay, let's try that again.
Okay, there you go.
I just explained to folks thatyou know, if you have a denial
of it like that and they giveyou your reasons for your denial
, they have to give you a basisand a reason for the denial.
(11:55):
And saying you're fat and godiet is not a reason reason for
denial.
It's saying you're fat, go diet.
It's not a reason for denial.
Basically right.
Bethanie Spangenberg (12:02):
Yeah, and that medical opinion didn't
discuss specifically thatveteran and what the veteran's
risk factors were.
So they were pulling all theserisk factors out of thin air,
but none of them applied to theveteran a veteran.
So in that case, you know,there's the only way that, in my
(12:23):
opinion, when you're looking atseeking help from legal side or
from a medical side, in myopinion the really the best
avenue is to get a medicalopinion in that instance.
Ray Cobb (12:32):
Bethany, I have a question for you.
When I, when I went through mysleep apnea claims and
everything At that time in theVA, the only medical condition
that they recognized that wouldcause sleep apnea, and in the
sleep apnea clinic at Vanderbilt, what they would state would
(12:55):
cause it, beside the ones thatyou just mentioned, was a heart
condition, and your heartcondition is a part, if you look
(13:16):
, according to the AmericanHeart Association.
I haven't looked at it inseveral years because you know I
want my case so, but back oh,I'm going to say 2011, 2012,
that the American HeartAssociation conceded that sleep
apnea is a directive as resultsof a heart condition.
So, therefore, if you had thediagnosis of steinic heart
(13:39):
disease which I did have, and inmy case I'd had open heart
surgery with three blockages anda double bypass, they granted
mine real quick.
I actually in my records that I, when I did my claim, in my
(14:01):
letter I stated very clearlythat it was secondary to my
stentic heart disease.
I didn't give them a chance tolook anywhere else that letter
that the American HeartAssociation, on a given date,
had declared that sleep apnea isthe direct results of a heart
(14:25):
condition or some form of aheart disorder.
So I'm not for sure that whatyou're trying to do there.
If there really is any medical,that would be my question what
medical evidence is there thatcombines the two, the sleep
(14:47):
apnea to the medical condition?
Is there any test?
Is there any evidence besidethat garbage that they cut and
paste all the time and I've seenthe same thing.
Matter of fact, they'll usealmost the same verbiage in
diabetics.
You know age and weight and allthat as being a diabetic, not
(15:10):
the fact that you were sprayedwith Agent Orange.
But is there some direct resultfrom what you were working on
and had that denial?
So yeah.
Bethanie Spangenberg (15:25):
So there's actually there's a lot of
literature out there.
Now.
When I first started doing this, when I first transitioned away
from the VA into doing more ofthe accreditation education,
doing my continuing legaleducation, I first did not
believe that there was arelationship between sleep apnea
and PTSD or mental healthconditions in general.
(15:48):
When I went to a NOVAconference National Organization
of Veteran Advocates there wasthe I always do this there was
an individual there as arepresentative from the VA who
was medical and he stood infront of 300 attorneys and said
(16:11):
there is literature out therethat connects PTSD and sleep
apnea and that was like 2017,2018.
And so I at that point I waslike you know, I really got to
understand this thought processand what apnea?
And that was like 2017, 2018.
And so I at that point I waslike you know, I really got to
understand this thought processand what that means, and so I
started digging into theliterature.
Well, now that there's more dataout, there is signals in the
brain waves.
So when you do an in-lab sleepstudy and they capture the
(16:35):
brainaves, they say that the REMsleep disruption is a
significant sign for those withPTSD and they say it's like the,
not the gold standard, but it'sthe flag of having some type of
mental health disorder.
Anxiety or PTSD is when the REMsleep cycles are disrupted, or
(17:02):
PTSD is when the REM sleepcycles are disrupted.
The other part is for sleepapnea, and a lot of medical
teaching is segmented.
They talk about the endocrineorgans or they'll transition to
just the cardiology organs andfunctions and just the lungs,
but they never really talk abouthow those systems communicate
(17:23):
and intertwine.
So when it comes to mentalhealth and it comes to insomnia,
it comes to diseases or mentalhealth issues that cause sleep
fragmentation.
What happens is that sleepfragmentation doesn't allow the
quality of sleep that you need,so you're changing in and out of
these sleep cycles more rapidlyin order for your body to kind
(17:45):
of catch up.
And I personally watch.
I have data that captures howmuch REM that I get, how my
latency, how long it takes me tofall asleep.
I look at my movement.
So I have personally looked atmy own data for the last year to
(18:08):
really understand my own bodyand that has contributed to my
understanding of mental healthconditions and sleep apnea.
The other literature that's outthere talks about how
musculoskeletal conditions cancontribute to sleep
fragmentation because of thepain, and if their pain is not
well controlled, then they arehaving the sleep fragmentation
(18:32):
as well.
Then there's research out therethat talks about the
medications that are used totreat certain ailments.
Those medications arepreventing an individual to
cycle through the differentsleep stages, and it's causing,
during certain sleep stages iswhen your body starts to relax
(18:53):
and you're not getting the goodopen airway that you normally
would.
So when you're disrupting yournormal sleep cycle, you actually
have more laxity in the back ofyour throat and your body is
not as responsive.
So if you're choking or gaspingfor air, you're in a deeper
sleep before your body starts torespond.
(19:14):
So deeper sleep, lower oxygenand then your body finally
arouses.
So it's, there's a lot outthere now, but like I said to
start with, I, I was not sold, Iwas not bought, I didn't buy
into it.
J Basser (19:32):
But you had to make your own decision and your own.
You know, you had to look at itand kind of make your own mind
up.
That's a good, that's a goodshows good character doing that,
you know.
Bethanie Spangenberg (19:43):
There's also research out there too, on
the VA website, that talks aboutPTSD and sleep apnea and the
relationship between the two.
So for the CMP examiners to saythat they're two separate
conditions in entirety andthere's no relationship, they're
failing to look at theliterature that's out there.
(20:04):
And the VA has literature outthere on their website that says
it's education for the veteranswith PTSD that they should be
undergoing a sleep study becauseof the relationship between
PTSD and sleep apnea, and we usethat in our reports as well.
J Basser (20:21):
Is there any.
I mean say, for example, from aVA rating purpose to the
situation if you rate for sleepapnea.
I think it's listed in theTitle 38 portfolio under that.
Is it still in the lungsrespiratory or did they separate
it out?
Bethanie Spangenberg (20:44):
There's a lot of research out there about
upper sinusitis causing sleepapnea too.
It's a lot that we're seeingnow because sinusitis, rhinitis
being presumptive when it comesto the rhinitis what we're
seeing is a lot of veterans aregetting kind of a delayed
diagnosis.
So they may have been diagnosedwith sleep apnea 10 years ago
(21:11):
and they're just now getting thediagnosis of sinusitis and
rhinitis.
And when we look at those caseswe really have to look at that
veteran's history and understandwhat factors are playing a role
in the sleep apnea, because ifthey have other primary factors,
then we can't write the nexusfor sinusitis causing sleep
(21:32):
apnea.
J Basser (21:34):
So hopefully that Ray was in the talk about heart
disease.
I mean, I know there's a lot offolks that have sleep apnea,
that have acral fibrillation andthey have the strokes that are
triggered by APF.
You know, if you put clots inyour brain, they wind up passing
away because of that andbasically it recalls the sleep
apnea because it triggered yourAPF to take effect and you fired
(21:55):
a clot in your history.
Bethanie Spangenberg (21:57):
Yes.
J Basser (21:57):
So that's, you know, only in another world.
Maybe down in Tennessee they'llget it, but nobody here is
going to get thatservice-connected.
Bethanie Spangenberg (22:06):
That's actually part of the workup in
the clinic.
If somebody has AFib, then wework them up for sleep apnea,
because the sleep apnea cancause the AFib.
J Basser (22:17):
Mm-hmm, or you can make it worse too, though.
Bethanie Spangenberg (22:20):
Or vice versa too?
J Basser (22:22):
Yeah, but I mean for writing.
I mean, if you were already100% for lung disease, it really
wouldn't matter, would it?
Bethanie Spangenberg (22:29):
No.
J Basser (22:30):
Because it puts you on the pyramid, trying to push you
off the top.
Bethanie Spangenberg (22:36):
You know I've seen some of those trying
to say, like well, they'll ratesleep apnea over asthma, and I
talked to an attorney about thisbefore.
So if you're a veteran outthere, that's getting one rating
decision for both asthma andsleep apnea.
You need to argue that, Becausewhen I talked to the attorney
about it, what they said isthere's a difference, Because in
(22:57):
the regulations there's a commathat separates the two versus a
dash.
So in the legal jargon thatI've learned, there's a
difference between a comma and adash.
J Basser (23:08):
So you should be getting rating decisions for
both.
Well, put me out of my misery.
All right, all you advocatesand all you agents listening to
this, get off the table andstack your balls up, you know,
and get ready to break, becausewe got a game to play.
(23:30):
Yeah, all because of a comma.
Good idea.
Bethanie Spangenberg (23:43):
So I'd like to go ahead and move on to
the next one.
Okay, this is also about sleepapnea.
Am I cutting out again or am Idoing all right?
J Basser (23:56):
No, you're doing, you're fine, you're rolling
pretty good now.
Bethanie Spangenberg (23:58):
All right, good, am I cutting out again or
am I doing all right?
No, you're doing fine, you'rerolling pretty good now, all
right, good.
So for this veteran, let's seehere Okay, this is, I got them
together.
I knew I had more than six,anyways, okay.
More than six, anyways, okay.
(24:23):
So this veteran was denied forobstructive sleep apnea and he
was seeking a service connectionthrough obesity.
Okay, so there is an obesity asan intermediate step which you
can't get service connected forobesity, but you can get service
connected through obesity andI'll talk a little bit about
that.
So what this veteran said isthat his service-connected
(24:44):
physical conditions caused himto become obese and then that
obesity caused sleep apnea andyou can get service-connected
for that.
And we've seen it, we've workedon them, we understand the
memorandum and that's how weprepare a lot of these opinions.
So for this veteran, he was 50%service-connected for
(25:07):
depression, 10% for his leftknee and 10% for his right knee
and 20% for his left ankle.
And in this denial okay, theexaminer went through here and
(25:28):
11 times they said that obesityis primarily due to consuming
more calories than the bodyburns off, which is a choice.
Therefore, his sleep disorderand left ankle are not medically
(25:51):
related.
Okay, so they took the sleepdisorder and the left ankle and
said no, it's because you'reeating more calories and the
body burns off and that's yourchoice.
So then the next time they sayno, obesity is primarily due to
consuming more calories than thebody burns off, which is a
choice, so your sleep disorderis not related to your irritable
(26:11):
bowel syndrome.
And they go on and they sayindividually that the depression
isn't causing the sleep apnea,because sleep apnea is caused by
obesity and obesity is a choice.
So 11 times in their medicalopinion they say this Ridiculous
(26:32):
, ridiculous.
So when you write an opinion oryou get an opinion for obesity,
as an intermediate step youhave to state that the veteran's
conditions caused them to beobese and that obesity was a
substantial factor in thedevelopment of sleep apnea or
(26:56):
whatever condition you'reclaiming in the development of
sleep apnea or whatevercondition you're claiming.
And then the medical examinerhas to determine if they were
not obese, would they still havedeveloped the sleep apnea or
the condition that they'reclaiming?
So for this veteran we statedthe veteran's left knee, right
knee, left ankle and majordepression caused the veteran to
(27:16):
become obese.
Obesity is a substantial factorin the development of this
veteran's obstructive sleepapnea.
The veteran would not havedeveloped obstructive sleep
apnea if the veteran was notobese.
So he was service-connected formultiple things that prevented
him from being physically activeand his depression was
(27:37):
specifically stated, that he haddifficulties with motivation
and with mood and when you'retrying to maintain your weight
or trying to lose weight youhave to be motivated, you have
to be focused and able toaddress anything that you
consume and the exercise and thepain.
You have to be able to juggleall these things.
(27:59):
And this veteran did notdemonstrate that he was capable
of doing those things.
So in our letter, after weexplain about how his physical
ailments limited him and hismental health condition
prevented his motivation at thebottom we kind of argue with
them and we say kind of argue.
(28:20):
I guess it says um.
One phrase seen 11 times in thenexus report states that obesity
is primarily due to consumingmore calories than the body
burns off, which is a choice.
However, this phrase is notsupported by medical literature
and it wasn't.
It's not supported by medicalliterature and it wasn't.
It's not supported by medicalliterature citations and I'm
unable to find medicalliterature to support the
(28:42):
repeated phrase from thecontract examiner.
One piece of medical literaturefound states that many
healthcare providers andpatients share the belief that
obesity is a product of poorlifestyle choices that are under
the voluntary control ofaffected individuals.
So I take that literature and Italk about how the veteran
(29:06):
basically needs to have all ofhis ducks in a row.
And guess what, if a veterandoesn't have his ducks in a row
and he's filing for serviceconnection, that's his
prerogative.
You know, he didn't ask forthis mental health issue.
He didn't sign up to say, well,I'm going to walk away from
here being depressed and havingissues after I leave service.
So I just found it fascinatingthat the mindset and this is
(29:30):
from 2022, this decision was.
So I just find it fascinatingthat the mindset is that, well,
you're overweight and it's yourfault.
So I just find it fascinatingthat the mindset is that, well,
you're overweight and it's yourfault.
So, and no consideration of theother ailments that this
individual had, did thisindividual diabetic?
By chance?
No, they had no.
(29:55):
Their only risk factors weretheir physical ailments, and
they're.
I was trying to see.
Normally we put the BMI in here, but I'm not finding it real
quick.
So they did not have diabetes.
He might.
He might develop it later andthen he can get service
connection for that.
J Basser (30:19):
And then they'll get service connection for that.
Ray Cobb (30:21):
Well, that was a point I was going to question and I
was going to state my name.
American Diabetes Associationdeclares that obesity is caused
due to the fact that the bodydoes not accept the insulin to
which it produces and in somecases, does not accept the
insulin which is my case isinjected or, in your two cases,
(30:44):
it's done by the pump andtherefore you become obese and
continue to grow, and which isthe reason for that.
That's how come?
Uh, now we have oipic, whichworks, you know, yes, and that
offsets the problem that thethree of us had with our
diabetes and bad insulin, orbody not accepting our insulin,
(31:08):
which causes obesity, whichcauses a sleep apnea, and it's,
you know, everything issecondary.
It might be the third secondarydown the road, but it's still
secondary.
Bethanie Spangenberg (31:21):
Yeah, yeah .
J Basser (31:24):
Any questions about that one I?
Bethanie Spangenberg (31:26):
think I'm going to switch topics.
J Basser (31:29):
Yeah, let's switch over.
But that poor guy, I mean it's.
You know, some of these doctorssay this.
I mean they're supposed toattend some type of training to
understand this.
You know this.
I mean they're supposed toattend some type of training to
understand this.
You know, and you cannotinterject your personal,
political or whatever views intodoing your job.
You need to be able to followthe rules.
As a quality assurance expert,I would kick that out in a hurry
(31:49):
.
You know, because you have togo by what's listed in
documentation.
You know you can't just makeyour own, yep.
Bethanie Spangenberg (31:58):
Okay, so let's since you talked about
that, let's talk about, let'ssee.
There's one on diverticulitisthat I want to talk about, let's
(32:28):
see.
Okay, let's talk about this one.
So this one is a ratingdecision from September of 2024.
And this veteran was seekingservice connection for his neck
condition.
Okay, he served 15 years in thearmy as a helicopter pilot.
Okay, so his rating decisionsays okay, so he submitted a
(32:54):
private opinion by hisorthopedic physician and it says
the January 18th 2024 medicalopinion from Dr So-and-so
indicated that your degenerativedisc disease of the neck
originated from service inrelation to parachuting
repelling and an aircraft crashand over 2,200 hours flying with
(33:19):
heavy equipment worn andconstant aircraft vibration.
To me that's logical.
That is pretty physicallyintensive and doing that for 15
years, you're tearing your bodyup.
Okay, the rating decision goeson to say this is according
because we wrote a nexus letterand it says that our Valid for
(33:41):
Vets medical expert stated thatthe veteran endorsed neck and
back pain that continued andworsened after service.
He continued to fly medicalhealth.
Oh sorry, the examiner statedthat you endorsed neck and back
pain that continued and worsenedafter service, continue to fly
medical helicopters and have twoor three flare-ups per year.
(34:03):
So what we were doing was justrestating the veteran's
testimony in that aspect.
So they use that as a reason todeny.
Because here we go while theprivate medical opinions and
medical literature supportevents that show causation of a
cervical spine degeneration, themedical evidence during and
(34:25):
following service do not supportthe conclusion that a chronic
condition was present during orafter service, lack probative
value as they do not address thesudden onset of symptoms in
March of 2022 or the impact offlight activities following
service.
So after this veteran got out ofthe military, he decided to go
(34:48):
on and fly medical helicoptersand in 2022, he woke up and he
had severe pain in one of hisarms.
And this rating decision goesthrough and quotes medical
records from October, from March, from December, from March,
(35:22):
from December, and what it talksabout is how this veteran would
lift weights or how thisveteran suddenly developed this
arm pain and come to find outthere was no medical opinion
sought for this.
This is the rater copying andpasting the notes from the
medical visits and saying, well,there's not a nexus there,
(35:46):
because you have all these otherconditions and all these other
treatment records that you thatweren't discussed, and so then,
therefore, it's, it's um, notservice connected.
So specifically it says themedical opinions lack probative
value because they do notaddress the sudden onset of
(36:06):
symptoms in march of 22 or theimpact of flight activities
following service.
So this is a raider.
Raider providing their ownmedical opinion to deny the
veteran and for this you have alot of practice in medicine.
No, and originally when we sawthis claim, I told the veteran
(36:29):
that because what happens iswhen we write a nexus letter, we
will go on and say we'll writea rebuttal if you're denied for
medical reasons.
So for me this was not amedical reason, this is a legal
issue, because you have anon-medical person, you have a
lay person creating their ownmedical opinion and it has no
(36:51):
legal value.
That means nothing from a legalaspect.
So we weren't going to writethe rebuttal and I said go talk
to a representative, let us knowwhat they say.
So a couple months goes by andhe comes back and he says hey, I
talked to my representative.
They still want a nexus letterto kind of refute you know the
(37:11):
rating decision.
And so we did, based off of therepresentative's request.
So in our rebuttal I talk aboutthe veterans, all of his
veterans, all of his serviceconnections.
So during military service heparticipated in cadet boxing
(37:33):
during which he sustainedmultiple head and facial traumas
.
He is currently serviceconnected for a deviated septum
attributed to facial trauma.
So if you have facial traumayou're also getting the impact
on your neck.
So you're having the reboundand the trauma from your neck.
And then I talk about how heserved as a helicopter pilot,
(37:54):
logging over 2,200 hours offlight time.
In 2004, he sustained injuriesduring a helicopter crash while
attending flight school.
So they were up in theirhelicopter and something
happened and they got lucky inthe fact that when they dropped,
they hit a tree and they sat inthe tree, but he ended up
(38:17):
breaking his tailbone and he hada TBI.
Okay, so he's 0%service-connected for the TBI
because of head trauma.
Head trauma again, you'reimpacting the cervical spine.
And then I talk about how he'sservice-connected for a tailbone
injury related to the crash.
So this crash was a significanttrauma to the body in general.
(38:41):
And so this veteran's story isbecause of the tailbone injury,
he had trouble sitting and hereally struggled and manipulated
his body so that he couldcontinue to fly, and all those
stressors impact the rest of thespine.
So then I go on.
(39:01):
Because they said that wedidn't talk about how we fly
medical helicopters, I said,following his military service,
the veteran has not experienceda traumatic injury, traumatic
brain injury, he has notexperienced head trauma and he
has not been involved in ahelicopter crash.
Because they want us to talkabout his post-service stuff.
Well, he didn't have ahelicopter crash after service.
(39:23):
He had it in service.
So the impact is much differentthan what we're looking at with
his current occupation.
And then I talk about how themedical helicopters are less
physically demanding compared tohis 15 years of military
service.
I said contrary to the inferencein the rating decision, the
(39:43):
veteran did not experience asudden onset of cervical spine
symptoms in March of 2022.
Instead, he woke with nervesymptoms affecting the upper
extremities.
The sudden development of nervesymptoms during sleep is
commonly observed in individualswith degenerative disc disease.
(40:04):
And then I talk about his MRI,which also supported that it
wasn't a sudden onset.
The prolonged nerve pressurecaused by sleeping position in
the presence of cervical discdisease can exacerbate the
condition.
The March 2022 report of nervesymptoms is clinically
(40:25):
consistent with an exacerbationof the veteran's cervical spine
condition.
So they're trying to argue thatyou didn't have an issue until
you woke up and had numbness inyour arm.
No issue until you woke up andhad numbness in your arm.
No, that's why you're notmedical.
That's why you're not qualifiedto write an opinion.
Well, 15 years as a helicopterpilot, cadet boxing, repelling
(41:09):
parachuting and then you get outand, like eight years after
discharge, you all of a suddenwake up suddenly with issues.
I I just on this one, the.
The takeaway from this is youneed to understand when you need
legal representation, medicalrepresentation or medical help.
In this case, when a lay personprovides a medical opinion and
(41:29):
they're not quoting a medicalexaminer, they're not issuing at
least as likely as not then youneed to argue that from a legal
perspective.
Yes, you can get the help of anexus, but you also need
somebody.
If you're willing to take thaton by yourself I don't know that
I would recommend that.
I think you need an advocate inthose cases.
But yeah, that's the takeawaytakeaway.
(42:12):
So the next one I want to talkabout I know we've got like 18
minutes left, so some of these Imight just dance around this
one here that I want to talkabout briefly is the
diverticulitis one this ratingdecision.
The first rating decision isMarch of 2024.
And the second one is June of2024.
And this is a veteran who hadmultiple dates of service and it
(42:34):
was almost consecutive For like10 years.
There was only a six-monthperiod that he was not active.
The rest of those 10 years hewas on active orders and so he
has multiple DD-214s and in thefirst rating decision they miss
two of the DD-214 service datesOkay.
(42:55):
Then on the second ratingdecision, they missed one period
of service and the one periodof service they missed was that
period that the veteran was seenfor his claimed condition.
Almost seems intentional.
(43:15):
So they excluded November 2009to January 18th of 2010.
He was seen for his claimcondition on January 16th 2010.
He was in the emergency roomseeking treatment for abdominal
(43:36):
pain, for diverticulitis.
He was on active orders and forthose 10 years he was only ever
off active orders for sixmonths.
So when they denied his serviceconnection, they're saying that
there was no treatment for thecondition in his service
treatment records.
Your service treatment recordsdo not contain complaints,
(43:58):
treatment or diagnosis fordiverticulitis or diverticulosis
.
So when we write our nexus we'resaying hey, on your rating
decision, you forgot a period ofservice and during that period
of service he was seen fordiverticulitis, a CT scan was
(44:19):
done and he was given medicationfor treatment of the condition.
So in this case he probablydidn't need a nexus letter.
He probably needed someone tosay hey, va, you missed this
period of service and, by theway, during that period of
service I was also treated forthe condition.
So from the medical examinerside of things, we're not
(44:42):
confirming the dates typically.
In this case it was becausethat he received treatment that
I was like wait a minute, whyisn't this date in here?
So as the veteran, you need tomake sure that the VA is
recognizing all periods ofservice that you have DD-214s
for.
The information that is in thatparagraph is the information
(45:06):
that is given to the C&Pexaminer.
So if they're missing a periodof service, that C&P examiner
isn't getting that period ofservice either.
Any questions on that one?
Ray Cobb (45:22):
No questions.
But it seems to me it's obvious.
You know we have still to thebest of my knowledge, we're
still doing a 94.6% denials.
So it's obvious they're lookingfor reasons to deny it, or
making up reasons for denying it, or overlooking information,
(45:45):
like in this case, that theywould not have been able to
overlook, just so that theycould continue with the denial
and say I'm going to letsomebody else make this decision
, not here in the regionaloffice, not on my watch, and I
think that's the thing we'vebeen seeing going on for
numerous years and I don't thinkthere's any end in sight to
(46:09):
that.
I think we've got to do justexactly what you're saying.
The veteran.
Unfortunately, it's ourresponsibility as a veteran to
make sure that they have all theinformation they need and when
you get a denial, make sure thatthey looked at all the
information that is in yourmedical records.
(46:30):
You can do that by gettingsomeone like you or some of the
other agents around the countryto be able to help you with that
.
And if you're, you know, ifyou're not, you got to be pretty
(46:56):
savvy, or learn to get prettysavvy in order to beat the VA at
their own game.
And the best compliment I hadwas just a few months ago, when
a patient advocate says boy, youreally know your way around the
VA.
You bet I do, you know, and soyou know.
And I told him.
I said you bet I do and I alsoknow the law, and that's one
thing that a lot of times youguys don't follow.
(47:18):
You don also know the law, andthat's one thing that a lot of
times you guys don't follow.
You don't follow the law.
Yes, absolutely, and so youknow.
There's some things guys outthere I hate to say this you
just can't do dealing with a VAlike you do any other
organization or any other group.
You have got to be involvedyourself.
(47:39):
You've got to take and make theeffort.
You or your spouse or a lovedone, such as a son or daughter,
has got to take theresponsibility, help guide you
through this and look up all theinformation and make sure that
they follow the law, because ifthey break the law, there's no
(48:00):
deputy sheriffs go to come andget them.
Yep, you got to go get them.
You got to be the deputysheriff, you got to be the
prosecutor, you got to be thejudge, and so you got to take
the time to do that, and whatyou pointed out tonight to me is
an excellent examples, everyone of them, how these denials
(48:21):
should not have ever been deniedto start with, and it's because
of a slip up, not necessarilybecause of the veteran, but
because of the VA regionaloffice, yep.
Bethanie Spangenberg (48:34):
Now the other big takeaway like.
I want for listeners to have fortonight is if you get a denial,
whatever reason they give,don't feel like you're being
singled out, don't feel likeyou're special because they hand
it out so much.
And it's absolutely ridiculousand I think the most ridiculous
(48:55):
one that I've seen is going tobe our last one that I'm going
to talk about here on earlier,and some of it really.
You know, if you're anempathetic person and you care
about people, some of these canreally just devastate you and
make you sick.
So don't feel special out there.
Ray Cobb (49:18):
If you know you got this condition, if this
condition you know happenedwhile you were in the military,
then stand up and fight andcontinue to fight until you win
your case.
It took me 11 years to win myfirst one.
I still didn't keep fighting.
I mean, I was told numeroustimes how is it that you say it,
(49:38):
john, don't poke the bear?
I was told.
Well, you've got 100%.
Why do you want more?
Because I deserve it, becausethe law says I'm entitled to it
and that's it, you know.
If you're entitled to it, getit.
If you're not entitled to it,if you don't have those
conditions, then don't pursue it.
Bethanie Spangenberg (50:00):
Alright, are we ready for the last one
here?
It?
All right.
Are we ready for the last onehere?
All right.
So I think what I want to do onthis one is I want to talk
about this veteran's historyfirst, before we get to the
(50:21):
denial.
Okay, so this is a case from2016, 2018, we got involved, and
so the service history is theveteran served in the army from
October 1999 to March of 2004.
And then again from February2008 to January of 2014.
(50:41):
So we have five, 10 years inthere, or maybe a little bit
more.
So the veteran served in combatand was diagnosed with
depression, overdose, alcoholuse and PTSD while on active
service, he was being treatedfor substance abuse associated
(51:02):
with his mental health disorderswhile on active duty In
September 2012,.
While he's on active duty, forthe depression, overdose alcohol
use, ptsd, his medicaldischarge summary states that he
was going to be evaluated forpossible suicide by psychiatry.
(51:23):
However, this was unable to bedone, so the military did a
disservice, I think, there.
At his follow-up for hishospitalization, the clinician
documented that the veteran'srecollection of events prior to
the suicide attempt the recordsdocument that the veteran went
through his army things andbegan to have a panic attack
(51:45):
triggering by triggered bymemories of combat.
So from that point on, theveteran does not recall the
events that followed, which ledto his mental breakdown.
So he's having psychotic issues.
Okay, so he has aneuropsychiatric evaluation and
while while he's in service, therecords show that he has had
(52:08):
extreme emotional turmoil and Iquote extreme emotional turmoil
that complicate his currentclinical picture.
So they can't figure out.
I think what it came down to ishe had a TBI and they couldn't
really figure out if it was TBIor if it was his mental health
issue.
But they finally decided thatit was because of his mental
health that he's having all thismemory loss and psychotic
(52:30):
issues and substance abuse.
So he was service-connected fora back condition with
radiculopathy and he was treatedby the pain clinic and he was
prescribed Percocet by the painclinic for his back pain In
March of 2014,.
(52:52):
So this is two months after hewas discharged.
A clinician documented that theywere concerned with his history
of mental illness and alcoholabuse and I outrightly told him
he is at higher risk for abuseof opioids, so we have to
tightly monitor usage.
In his compensation and pensionexam, the examiner documented
(53:17):
that he had active suicidalideation, thoughts of hurting
himself and he demonstratedavoidance of external reminders
and distressing memories.
So when a person starts todemonstrate those activities,
they're starting to drinkalcohol or use drugs because
they're trying to avoid thosememories and trying to do what
(53:39):
they can to just kind of forgetthat whole time.
Okay, so in the ratingsdecision, the rating decision
denied the widow's applicationfor benefits.
I didn't mention this, sorry.
He died from acute fentanylintoxication and let me see the
(54:05):
date on that.
That's the most important part.
Oh, the veteran died on March14th 2016 from acute fentanyl
intoxication.
That was the very next sentence.
I didn't read it.
So, yeah, so he's less than twoyears out of service, he's got
all these mental health issues,there's concerns for him using
these opioids because of hishistory of alcohol abuse, and so
(54:28):
he dies from acute fentanylintoxication and that's what is
on his death certificate isacute fentanyl intoxication.
So the VA denied the widow'sbenefits for cause of death and
this is what it says.
The death certificate showsthat the veteran died on March
14, 2016, and the cause of deathwas recorded as acute fentanyl
(54:48):
intoxication.
The US National Institute ofHealth US National Library of
Medicine website provides animportant warning for fentanyl
Fentanyl should only beprescribed by doctors who are
experienced in treating pain incancer patients.
Fentanyl should be used only totreat breakthrough cancer pain.
(55:10):
There is no medical evidence ofrecord that the veteran was
being treated for any cancer andthat is why they denied the
widow's benefits.
And that was not a medicalopinion.
That was a rater copying andpasting from a website.
That is sad.
(55:36):
What can you say?
So when we wrote this nexus, weobviously outlined what I read
to you, his history and wetalked about how, um, what the
suicidal ideation and avoidancelike he was introduced to
opioids by the pain clinic inactive service because of his
(56:02):
physical conditions.
So his introduction to opioidswhich fentanyl is an opioid it
was done by the military.
So if he has access or he canget opioids and he's trying to
self-medicate, that happens withmental health disorders
especially severe, and he hadeverything and they decided that
(56:24):
well, he doesn't have cancer sohe shouldn't have been taking
fentanyl.
Ray Cobb (56:45):
Yes, Bethany.
Have these denials?
Have they been appealed and, ifso, were they appealed?
How were they appealed?
Did they go to the board or didthey just ask for a higher
level or supplemental claim?
Bethanie Spangenberg (57:05):
So we don't get a lot of the process
if the veteran comes to usdirectly.
The opioid case came to usthrough an attorney because they
obviously were representing thewidow and needed that opinion
there.
The case on the diverticulosisthat came to us directly from
the veteran and he's going toappeal that with our medical
(57:27):
opinion, that was a recent oneso we don't have any details on
that one.
Same with the helicopter pilotwe suggested he get legal
representation and so he'sworking with a legal
representative with a nexus fromus.
And then the sleep apnea one.
This one was sent to the boardand, knowing this attorney, it
(57:51):
was one, otherwise I would haveheard from him.
And then this last one, or thefirst one that we talked about
when it comes to sleep apnea,and it talked about all these
risk factors he didn't have.
He won with the Nexus letterfrom us and he didn't have
representation on that.
Ray Cobb (58:11):
The only thing to remember right there that you
just pointed out every one ofthose cases either did or are
continuing to fight for theirdisabilities, that they deserve,
and that's the most importantthing, don't give up.
Go wherever you need to go toget the proper representation,
(58:32):
but get it done.
Bethanie Spangenberg (58:34):
And they were all to fight those.
They should have.
Every single person, everysingle veteran, every single
case that I talked about tonightand I've got more over here
that we didn't get to, theyshould have fought it.
It's ridiculous the nonsensethat the va has and the audacity
to tell the widow that becauseyour, your husband, didn't have
cancer, that you're, he's notservice connected for that.
(58:58):
I mean he had kids.
Ray Cobb (59:06):
The last one.
I don't know if you can saythis or not, but that didn't by
chance happen in Detroit,michigan, did it?
Bethanie Spangenberg (59:17):
No, but I can tell you where it did happen
and I want to say Philadelphia,philadelphia VA Regional Office
.
Okay, ray, you gotta close thisout oh okay, folks, thanks for
(59:49):
joining us.
Ray Cobb (59:49):
bethany, thanks for coming on tonight, great job.
I really enjoyed hearing allthis and, for those of you who
are listening, I think the mostimportant thing that you can get
out of this story is the cutand paste.
They don't.
Some of these guys don't evenknow what they're cutting and
pasting.
They just do it because they'veseen where it worked before.
(01:00:10):
So read it very carefully, makesure they're really talking
about your case and yoursituation.
But until next week, bethany,thanks for being with us and, on
behalf of John Stacy, this isRay Cobb saying good night and
we'll see you next week.
Bye, bye-bye, thank you.
Welcome folks to another episode of Exposed to
that Productions.
My name is John.
They call me Jay Besser.
I'm the host of this show Today.
I have.
Well, let's do the day.
Today is the first day of May2025.
It's a, you know, a littlerainy day, but it's pretty cool.
Here in Kentucky I've got myco-host, mr Ray Cobb.
How you doing, ray?
Ray Cobb (00:20):
I'm doing great.
How are you on this May Day Did?
J Basser (00:23):
you get out and play with the May Day Bulls.
No, no, no, I don't do thingslike that.
To me it's not playing May Day,it's called hobble around the
pole.
You know we got a treat for youguys.
We got a young lady that'squite regular on the show and
we're going to have a bigdiscussion tonight on certain
types of denials that youreceive from the VA.
(00:45):
You know, we thought all weektrying to find a nice fancy name
for this show and we finallyfigured it out.
This is Bethany Spangenberg.
She is the owner, ceo and theHMFIC of Valor for Vet.
Bethanie Spangenberg (01:01):
That's the Highly Mobile Foley
Instructor's Chair.
Oh my gosh, Took you a minuteto come up with that acronym.
How?
J Basser (01:09):
are you doing girl?
Bethanie Spangenberg (01:10):
I'm good.
You know, I'm actually reallyexcited because my seedlings are
sprouting and we've got lots ofrain and I'm hoping that this
summer we're not getting a bigdrought and hopefully I can have
a beautiful garden.
So today's a good day.
J Basser (01:29):
Get them.
Missouri wonders girls, you'llbe fine If you like green beans
stick beans and all kinds ofstuff.
Okay, well, it's awesome.
I know we were going to touchon these denials and I guess
we've been compiling some stuffand we've discussed a few of
them.
You know, in the process ofsetting up the show, and I think
(01:50):
you got a couple of good onesthere that the listeners need to
listen to, because some of thisstuff is it's like I don't know
they're on Mars or something.
I have no idea what they'redoing.
I don't think they do eitherTell you a lot of cases.
Bethanie Spangenberg (02:02):
Yeah, it's actually pretty surprising to
see some of the verbiage in therating decisions and you know,
doing what we do on a regularbasis.
We see a lot of ratingdecisions and we want to see
those.
So then that way we can kind ofrefute you know what their
medical expert is saying versus.
You know what we have in ourreports.
(02:24):
So we see a lot of medicalopinions.
We see a lot of denial letters.
One thing too with me being aformer compensation and pension
examiner, I pick up on a lot ofverbiage that is basically
copied and pasted from examinerto examiner and I know what
(02:45):
that's like to receive an emailfrom your regional office to say
, hey, use this verbiage.
And basically every examiner iscopying, pasting that into
their denial opinion.
And so every case that I havehere today it's hopefully a
learning lesson.
Have here today it's hopefullya learning lesson, something
that can teach veterans, veteranadvocates, and use some of my
(03:11):
frustration into a usefuleducation moment, I guess.
But I've got a whole stack ofthem and I kind of was just
going to randomly pick onebecause hopefully we can get
through them all, but there'squite a bit.
And I'd like to hear somestories from you guys as well,
(03:31):
because it always, you know,telling the stories helps other
veterans to kind of, you know,compare themselves to other
veterans.
So, all right.
One, two, three, four, five,six.
I have six right here.
John, give me a number One.
Two, three, four, five, six.
I have six right here.
John, give me a number Onethrough six.
J Basser (03:50):
See, my favorite number is no, let's not do that,
let's do three.
Bethanie Spangenberg (03:53):
Three, one , two, three, all right.
So one, two, three, four, fiveyeah, I have six, I thought I
had more than that.
So this one this is a case thatwe worked on, that we received,
and this is a rating decisiondated March 28th of 2024.
So a little over a year ago andthis veteran was applying for
(04:18):
sleep apnea and this ratingdecision says that their
previous denial for serviceconnection was confirmed and
continued.
So, in the details of, and ifyou have a rating decision with
you and you want to kind offollow along as we do some of
these, you know, I highlyencourage that, because there's
(04:39):
certain sections of the ratingdecision that, as a medical
examiner, we like to look at.
And when we look at the ratingdecision, we first start with
the dates of service that arerecognized by the VA, because
medical examiners don't gothrough each DD-214 to verify
when your service was.
We're relying on the VA to givethat information to us.
(05:00):
So that's the first thing welook at is the dates of service
us.
So that's the first thing welook at is the dates of service.
And when we jump down to whythe veteran was denied for their
service connection, the VA putwe requested a medical opinion
of the new evidence submittedwith your supplemental claim.
The conditions of sleep apneaand post traumatic stress
(05:20):
disorder are not medicallyrelated.
The obstructive sleep apnea isa separate entity, entirety from
the post traumatic stressdisorder and not medically
related.
The obstructive sleep apnea isa separate entity, entirety from
the post-traumatic stressdisorder and unrelated to it.
A thorough review of medicalliterature failed to demonstrate
a causal relationship.
A nexus has not beenestablished and it's interesting
that I started that.
We started with this onebecause when I was at the VA and
(05:44):
I was a compensation andpension examiner, we would
receive emails of verbiage toadd into the comment section of
our report and sometimes itwould be because new case law
came out, but sometimes inhindsight it was to circumvent
(06:05):
the rating schedule and thisverbiage.
If you've been denied for sleepapnea, you've probably seen
this same verbiage in yourdenial letter, because when they
say that sleep apnea is aseparate entity, entirely from
fill in the blank and unrelatedto it, a thorough review of
medical literature failed todemonstrate a causal
(06:27):
relationship.
That is all copied and pastedand, believe it or not, this was
not intentional.
But another rating decisionthat I have to discuss tonight
has the same verbiage and it'scompletely different areas of
the country.
So that should be a flag.
Whenever you look at yourrating decision, you see that
(06:53):
verbiage in there.
So if we jump down to the bottomsection, where they quote the
medical examiner's opinionfurther, the medical examiner
talks about what sleep apnea isand then it says quote the most
common cause of sleep apnea inadults is obesity, being a male
and advanced age.
Okay, that was the reason whythey denied this veteran.
(07:14):
Now there's no reference tomedical literature associated
with this.
There is no discussion aboutthe veteran's individual case.
And then the second opinionthat was issued was that there
was not a link found between thesleep apnea and the known toxic
(07:36):
exposures, including, but notlimited to, the veterans'
deployments to Kuwait.
A nexus has not beenestablished.
So that's another pattern thatwe're seeing.
They're throwing everythingagainst a toxic exposure-related
activity or a TERA, and a lotof times the veterans aren't
even claiming that way.
(07:57):
So that's an easy way for themto say a denial.
So if we actually look at theveterans' history, remember
there's three things that whythe veteran was denied that the
medical examiner said.
They said well, the riskfactors are obesity, being a
male and advancing age.
So then we pull up theveteran's history and he had a
(08:21):
sleep study done in July of 2019.
At the time of his diagnosis hewas 42 years old, which is not
a risk factor for sleep apnea,and his body mass index was 27,
which is not a risk factor forsleep apnea.
So the only risk factor thatthe CMP examiner identified that
(08:48):
was correct was that he was amale.
And so when we wrote the nexusletter, we said in July of 2019,
when he had this study, theonly conditions that he was
known to have and diagnosed withwas PTSD, vitamin D deficiency.
Those are the only two things.
(09:13):
So then we have to break down.
Okay, why has this veteran, whois not obese, who is not
advancing age, why did hedevelop sleep apnea?
And so for this one, we decidedthat the evidence suggested
that his sleep apnea wassecondary to his PTSD.
And in the bottom section ofour nexus letters this is where
(09:33):
I have the most fun is because Iopen up and I just kind of
hammer out like everything thatwas incorrect and so I put on
there.
You know, the veteran waspreviously denied service
connection.
A previous CMP examinerprovided a negative opinion,
stating that obesity, being maleand older age are the most
common causes of sleep apnea inadults.
However, this veteran does notfit the profile as he is neither
(09:56):
obese nor of advanced age.
The medical opinion lacks adiscussion on this veteran's
specific medical conditions andthe risk factors related to
sleep apnea.
So when you put the medicalopinion side by side, you know
ours has more probative valueand we're just arguing that you
know the VA opinion wasinadequate.
It's insufficient, it's notaccurate, it's not looking at
(10:19):
this veteran's?
Conditions.
I think she's frozen or lockedup.
J Basser (10:25):
You cut out a little bit or is it me cutting out?
Let me get it straightened out.
There she is.
It's lagging a little bit.
Can you hear it, Bethany?
Bethanie Spangenberg (10:46):
I see that .
Yeah, I can hear you.
Now Am I lagging?
J Basser (10:51):
Okay, it's lagging a little bit.
It must have about freezed youup.
I don't know if it's a plug-inproblem or something like that.
I know you got fast enoughinternet.
Sometimes it does that.
(11:13):
We're still set on 720.
Okay, we have folks beentalking about just denials and
some of the crazy stuff theycome up with.
You know, like you don't really.
I mean, you have to have sometype of medical nexus or
(11:35):
information.
Okay, let's try that again.
Okay, there you go.
I just explained to folks thatyou know, if you have a denial
of it like that and they giveyou your reasons for your denial
, they have to give you a basisand a reason for the denial.
(11:55):
And saying you're fat and godiet is not a reason reason for
denial.
It's saying you're fat, go diet.
It's not a reason for denial.
Basically right.
Bethanie Spangenberg (12:02):
Yeah, and that medical opinion didn't
discuss specifically thatveteran and what the veteran's
risk factors were.
So they were pulling all theserisk factors out of thin air,
but none of them applied to theveteran a veteran.
So in that case, you know,there's the only way that, in my
(12:23):
opinion, when you're looking atseeking help from legal side or
from a medical side, in myopinion the really the best
avenue is to get a medicalopinion in that instance.
Ray Cobb (12:32):
Bethany, I have a question for you.
When I, when I went through mysleep apnea claims and
everything At that time in theVA, the only medical condition
that they recognized that wouldcause sleep apnea, and in the
sleep apnea clinic at Vanderbilt, what they would state would
(12:55):
cause it, beside the ones thatyou just mentioned, was a heart
condition, and your heartcondition is a part, if you look
(13:16):
, according to the AmericanHeart Association.
I haven't looked at it inseveral years because you know I
want my case so, but back oh,I'm going to say 2011, 2012,
that the American HeartAssociation conceded that sleep
apnea is a directive as resultsof a heart condition.
So, therefore, if you had thediagnosis of steinic heart
(13:39):
disease which I did have, and inmy case I'd had open heart
surgery with three blockages anda double bypass, they granted
mine real quick.
I actually in my records that I, when I did my claim, in my
(14:01):
letter I stated very clearlythat it was secondary to my
stentic heart disease.
I didn't give them a chance tolook anywhere else that letter
that the American HeartAssociation, on a given date,
had declared that sleep apnea isthe direct results of a heart
(14:25):
condition or some form of aheart disorder.
So I'm not for sure that whatyou're trying to do there.
If there really is any medical,that would be my question what
medical evidence is there thatcombines the two, the sleep
(14:47):
apnea to the medical condition?
Is there any test?
Is there any evidence besidethat garbage that they cut and
paste all the time and I've seenthe same thing.
Matter of fact, they'll usealmost the same verbiage in
diabetics.
You know age and weight and allthat as being a diabetic, not
(15:10):
the fact that you were sprayedwith Agent Orange.
But is there some direct resultfrom what you were working on
and had that denial?
So yeah.
Bethanie Spangenberg (15:25):
So there's actually there's a lot of
literature out there.
Now.
When I first started doing this, when I first transitioned away
from the VA into doing more ofthe accreditation education,
doing my continuing legaleducation, I first did not
believe that there was arelationship between sleep apnea
and PTSD or mental healthconditions in general.
(15:48):
When I went to a NOVAconference National Organization
of Veteran Advocates there wasthe I always do this there was
an individual there as arepresentative from the VA who
was medical and he stood infront of 300 attorneys and said
(16:11):
there is literature out therethat connects PTSD and sleep
apnea and that was like 2017,2018.
And so I at that point I waslike you know, I really got to
understand this thought processand what apnea?
And that was like 2017, 2018.
And so I at that point I waslike you know, I really got to
understand this thought processand what that means, and so I
started digging into theliterature.
Well, now that there's more dataout, there is signals in the
brain waves.
So when you do an in-lab sleepstudy and they capture the
(16:35):
brainaves, they say that the REMsleep disruption is a
significant sign for those withPTSD and they say it's like the,
not the gold standard, but it'sthe flag of having some type of
mental health disorder.
Anxiety or PTSD is when the REMsleep cycles are disrupted, or
(17:02):
PTSD is when the REM sleepcycles are disrupted.
The other part is for sleepapnea, and a lot of medical
teaching is segmented.
They talk about the endocrineorgans or they'll transition to
just the cardiology organs andfunctions and just the lungs,
but they never really talk abouthow those systems communicate
(17:23):
and intertwine.
So when it comes to mentalhealth and it comes to insomnia,
it comes to diseases or mentalhealth issues that cause sleep
fragmentation.
What happens is that sleepfragmentation doesn't allow the
quality of sleep that you need,so you're changing in and out of
these sleep cycles more rapidlyin order for your body to kind
(17:45):
of catch up.
And I personally watch.
I have data that captures howmuch REM that I get, how my
latency, how long it takes me tofall asleep.
I look at my movement.
So I have personally looked atmy own data for the last year to
(18:08):
really understand my own bodyand that has contributed to my
understanding of mental healthconditions and sleep apnea.
The other literature that's outthere talks about how
musculoskeletal conditions cancontribute to sleep
fragmentation because of thepain, and if their pain is not
well controlled, then they arehaving the sleep fragmentation
(18:32):
as well.
Then there's research out therethat talks about the
medications that are used totreat certain ailments.
Those medications arepreventing an individual to
cycle through the differentsleep stages, and it's causing,
during certain sleep stages iswhen your body starts to relax
(18:53):
and you're not getting the goodopen airway that you normally
would.
So when you're disrupting yournormal sleep cycle, you actually
have more laxity in the back ofyour throat and your body is
not as responsive.
So if you're choking or gaspingfor air, you're in a deeper
sleep before your body starts torespond.
(19:14):
So deeper sleep, lower oxygenand then your body finally
arouses.
So it's, there's a lot outthere now, but like I said to
start with, I, I was not sold, Iwas not bought, I didn't buy
into it.
J Basser (19:32):
But you had to make your own decision and your own.
You know, you had to look at itand kind of make your own mind
up.
That's a good, that's a goodshows good character doing that,
you know.
Bethanie Spangenberg (19:43):
There's also research out there too, on
the VA website, that talks aboutPTSD and sleep apnea and the
relationship between the two.
So for the CMP examiners to saythat they're two separate
conditions in entirety andthere's no relationship, they're
failing to look at theliterature that's out there.
(20:04):
And the VA has literature outthere on their website that says
it's education for the veteranswith PTSD that they should be
undergoing a sleep study becauseof the relationship between
PTSD and sleep apnea, and we usethat in our reports as well.
J Basser (20:21):
Is there any.
I mean say, for example, from aVA rating purpose to the
situation if you rate for sleepapnea.
I think it's listed in theTitle 38 portfolio under that.
Is it still in the lungsrespiratory or did they separate
it out?
Bethanie Spangenberg (20:44):
There's a lot of research out there about
upper sinusitis causing sleepapnea too.
It's a lot that we're seeingnow because sinusitis, rhinitis
being presumptive when it comesto the rhinitis what we're
seeing is a lot of veterans aregetting kind of a delayed
diagnosis.
So they may have been diagnosedwith sleep apnea 10 years ago
(21:11):
and they're just now getting thediagnosis of sinusitis and
rhinitis.
And when we look at those caseswe really have to look at that
veteran's history and understandwhat factors are playing a role
in the sleep apnea, because ifthey have other primary factors,
then we can't write the nexusfor sinusitis causing sleep
(21:32):
apnea.
J Basser (21:34):
So hopefully that Ray was in the talk about heart
disease.
I mean, I know there's a lot offolks that have sleep apnea,
that have acral fibrillation andthey have the strokes that are
triggered by APF.
You know, if you put clots inyour brain, they wind up passing
away because of that andbasically it recalls the sleep
apnea because it triggered yourAPF to take effect and you fired
(21:55):
a clot in your history.
Bethanie Spangenberg (21:57):
Yes.
J Basser (21:57):
So that's, you know, only in another world.
Maybe down in Tennessee they'llget it, but nobody here is
going to get thatservice-connected.
Bethanie Spangenberg (22:06):
That's actually part of the workup in
the clinic.
If somebody has AFib, then wework them up for sleep apnea,
because the sleep apnea cancause the AFib.
J Basser (22:17):
Mm-hmm, or you can make it worse too, though.
Bethanie Spangenberg (22:20):
Or vice versa too?
J Basser (22:22):
Yeah, but I mean for writing.
I mean, if you were already100% for lung disease, it really
wouldn't matter, would it?
Bethanie Spangenberg (22:29):
No.
J Basser (22:30):
Because it puts you on the pyramid, trying to push you
off the top.
Bethanie Spangenberg (22:36):
You know I've seen some of those trying
to say, like well, they'll ratesleep apnea over asthma, and I
talked to an attorney about thisbefore.
So if you're a veteran outthere, that's getting one rating
decision for both asthma andsleep apnea.
You need to argue that, Becausewhen I talked to the attorney
about it, what they said isthere's a difference, Because in
(22:57):
the regulations there's a commathat separates the two versus a
dash.
So in the legal jargon thatI've learned, there's a
difference between a comma and adash.
J Basser (23:08):
So you should be getting rating decisions for
both.
Well, put me out of my misery.
All right, all you advocatesand all you agents listening to
this, get off the table andstack your balls up, you know,
and get ready to break, becausewe got a game to play.
(23:30):
Yeah, all because of a comma.
Good idea.
Bethanie Spangenberg (23:43):
So I'd like to go ahead and move on to
the next one.
Okay, this is also about sleepapnea.
Am I cutting out again or am Idoing all right?
J Basser (23:56):
No, you're doing, you're fine, you're rolling
pretty good now.
Bethanie Spangenberg (23:58):
All right, good, am I cutting out again or
am I doing all right?
No, you're doing fine, you'rerolling pretty good now, all
right, good.
So for this veteran, let's seehere Okay, this is, I got them
together.
I knew I had more than six,anyways, okay.
More than six, anyways, okay.
(24:23):
So this veteran was denied forobstructive sleep apnea and he
was seeking a service connectionthrough obesity.
Okay, so there is an obesity asan intermediate step which you
can't get service connected forobesity, but you can get service
connected through obesity andI'll talk a little bit about
that.
So what this veteran said isthat his service-connected
(24:44):
physical conditions caused himto become obese and then that
obesity caused sleep apnea andyou can get service-connected
for that.
And we've seen it, we've workedon them, we understand the
memorandum and that's how weprepare a lot of these opinions.
So for this veteran, he was 50%service-connected for
(25:07):
depression, 10% for his leftknee and 10% for his right knee
and 20% for his left ankle.
And in this denial okay, theexaminer went through here and
(25:28):
11 times they said that obesityis primarily due to consuming
more calories than the bodyburns off, which is a choice.
Therefore, his sleep disorderand left ankle are not medically
(25:51):
related.
Okay, so they took the sleepdisorder and the left ankle and
said no, it's because you'reeating more calories and the
body burns off and that's yourchoice.
So then the next time they sayno, obesity is primarily due to
consuming more calories than thebody burns off, which is a
choice, so your sleep disorderis not related to your irritable
(26:11):
bowel syndrome.
And they go on and they sayindividually that the depression
isn't causing the sleep apnea,because sleep apnea is caused by
obesity and obesity is a choice.
So 11 times in their medicalopinion they say this Ridiculous
(26:32):
, ridiculous.
So when you write an opinion oryou get an opinion for obesity,
as an intermediate step youhave to state that the veteran's
conditions caused them to beobese and that obesity was a
substantial factor in thedevelopment of sleep apnea or
(26:56):
whatever condition you'reclaiming in the development of
sleep apnea or whatevercondition you're claiming.
And then the medical examinerhas to determine if they were
not obese, would they still havedeveloped the sleep apnea or
the condition that they'reclaiming?
So for this veteran we statedthe veteran's left knee, right
knee, left ankle and majordepression caused the veteran to
(27:16):
become obese.
Obesity is a substantial factorin the development of this
veteran's obstructive sleepapnea.
The veteran would not havedeveloped obstructive sleep
apnea if the veteran was notobese.
So he was service-connected formultiple things that prevented
him from being physically activeand his depression was
(27:37):
specifically stated, that he haddifficulties with motivation
and with mood and when you'retrying to maintain your weight
or trying to lose weight youhave to be motivated, you have
to be focused and able toaddress anything that you
consume and the exercise and thepain.
You have to be able to juggleall these things.
(27:59):
And this veteran did notdemonstrate that he was capable
of doing those things.
So in our letter, after weexplain about how his physical
ailments limited him and hismental health condition
prevented his motivation at thebottom we kind of argue with
them and we say kind of argue.
(28:20):
I guess it says um.
One phrase seen 11 times in thenexus report states that obesity
is primarily due to consumingmore calories than the body
burns off, which is a choice.
However, this phrase is notsupported by medical literature
and it wasn't.
It's not supported by medicalliterature and it wasn't.
It's not supported by medicalliterature citations and I'm
unable to find medicalliterature to support the
(28:42):
repeated phrase from thecontract examiner.
One piece of medical literaturefound states that many
healthcare providers andpatients share the belief that
obesity is a product of poorlifestyle choices that are under
the voluntary control ofaffected individuals.
So I take that literature and Italk about how the veteran
(29:06):
basically needs to have all ofhis ducks in a row.
And guess what, if a veterandoesn't have his ducks in a row
and he's filing for serviceconnection, that's his
prerogative.
You know, he didn't ask forthis mental health issue.
He didn't sign up to say, well,I'm going to walk away from
here being depressed and havingissues after I leave service.
So I just found it fascinatingthat the mindset and this is
(29:30):
from 2022, this decision was.
So I just find it fascinatingthat the mindset is that, well,
you're overweight and it's yourfault.
So I just find it fascinatingthat the mindset is that, well,
you're overweight and it's yourfault.
So, and no consideration of theother ailments that this
individual had, did thisindividual diabetic?
By chance?
No, they had no.
(29:55):
Their only risk factors weretheir physical ailments, and
they're.
I was trying to see.
Normally we put the BMI in here, but I'm not finding it real
quick.
So they did not have diabetes.
He might.
He might develop it later andthen he can get service
connection for that.
J Basser (30:19):
And then they'll get service connection for that.
Ray Cobb (30:21):
Well, that was a point I was going to question and I
was going to state my name.
American Diabetes Associationdeclares that obesity is caused
due to the fact that the bodydoes not accept the insulin to
which it produces and in somecases, does not accept the
insulin which is my case isinjected or, in your two cases,
(30:44):
it's done by the pump andtherefore you become obese and
continue to grow, and which isthe reason for that.
That's how come?
Uh, now we have oipic, whichworks, you know, yes, and that
offsets the problem that thethree of us had with our
diabetes and bad insulin, orbody not accepting our insulin,
(31:08):
which causes obesity, whichcauses a sleep apnea, and it's,
you know, everything issecondary.
It might be the third secondarydown the road, but it's still
secondary.
Bethanie Spangenberg (31:21):
Yeah, yeah .
J Basser (31:24):
Any questions about that one I?
Bethanie Spangenberg (31:26):
think I'm going to switch topics.
J Basser (31:29):
Yeah, let's switch over.
But that poor guy, I mean it's.
You know, some of these doctorssay this.
I mean they're supposed toattend some type of training to
understand this.
You know this.
I mean they're supposed toattend some type of training to
understand this.
You know, and you cannotinterject your personal,
political or whatever views intodoing your job.
You need to be able to followthe rules.
As a quality assurance expert,I would kick that out in a hurry
(31:49):
.
You know, because you have togo by what's listed in
documentation.
You know you can't just makeyour own, yep.
Bethanie Spangenberg (31:58):
Okay, so let's since you talked about
that, let's talk about, let'ssee.
There's one on diverticulitisthat I want to talk about, let's
(32:28):
see.
Okay, let's talk about this one.
So this one is a ratingdecision from September of 2024.
And this veteran was seekingservice connection for his neck
condition.
Okay, he served 15 years in thearmy as a helicopter pilot.
Okay, so his rating decisionsays okay, so he submitted a
(32:54):
private opinion by hisorthopedic physician and it says
the January 18th 2024 medicalopinion from Dr So-and-so
indicated that your degenerativedisc disease of the neck
originated from service inrelation to parachuting
repelling and an aircraft crashand over 2,200 hours flying with
(33:19):
heavy equipment worn andconstant aircraft vibration.
To me that's logical.
That is pretty physicallyintensive and doing that for 15
years, you're tearing your bodyup.
Okay, the rating decision goeson to say this is according
because we wrote a nexus letterand it says that our Valid for
(33:41):
Vets medical expert stated thatthe veteran endorsed neck and
back pain that continued andworsened after service.
He continued to fly medicalhealth.
Oh sorry, the examiner statedthat you endorsed neck and back
pain that continued and worsenedafter service, continue to fly
medical helicopters and have twoor three flare-ups per year.
(34:03):
So what we were doing was justrestating the veteran's
testimony in that aspect.
So they use that as a reason todeny.
Because here we go while theprivate medical opinions and
medical literature supportevents that show causation of a
cervical spine degeneration, themedical evidence during and
(34:25):
following service do not supportthe conclusion that a chronic
condition was present during orafter service, lack probative
value as they do not address thesudden onset of symptoms in
March of 2022 or the impact offlight activities following
service.
So after this veteran got out ofthe military, he decided to go
(34:48):
on and fly medical helicoptersand in 2022, he woke up and he
had severe pain in one of hisarms.
And this rating decision goesthrough and quotes medical
records from October, from March, from December, from March,
(35:22):
from December, and what it talksabout is how this veteran would
lift weights or how thisveteran suddenly developed this
arm pain and come to find outthere was no medical opinion
sought for this.
This is the rater copying andpasting the notes from the
medical visits and saying, well,there's not a nexus there,
(35:46):
because you have all these otherconditions and all these other
treatment records that you thatweren't discussed, and so then,
therefore, it's, it's um, notservice connected.
So specifically it says themedical opinions lack probative
value because they do notaddress the sudden onset of
(36:06):
symptoms in march of 22 or theimpact of flight activities
following service.
So this is a raider.
Raider providing their ownmedical opinion to deny the
veteran and for this you have alot of practice in medicine.
No, and originally when we sawthis claim, I told the veteran
(36:29):
that because what happens iswhen we write a nexus letter, we
will go on and say we'll writea rebuttal if you're denied for
medical reasons.
So for me this was not amedical reason, this is a legal
issue, because you have anon-medical person, you have a
lay person creating their ownmedical opinion and it has no
(36:51):
legal value.
That means nothing from a legalaspect.
So we weren't going to writethe rebuttal and I said go talk
to a representative, let us knowwhat they say.
So a couple months goes by andhe comes back and he says hey, I
talked to my representative.
They still want a nexus letterto kind of refute you know the
(37:11):
rating decision.
And so we did, based off of therepresentative's request.
So in our rebuttal I talk aboutthe veterans, all of his
veterans, all of his serviceconnections.
So during military service heparticipated in cadet boxing
(37:33):
during which he sustainedmultiple head and facial traumas
.
He is currently serviceconnected for a deviated septum
attributed to facial trauma.
So if you have facial traumayou're also getting the impact
on your neck.
So you're having the reboundand the trauma from your neck.
And then I talk about how heserved as a helicopter pilot,
(37:54):
logging over 2,200 hours offlight time.
In 2004, he sustained injuriesduring a helicopter crash while
attending flight school.
So they were up in theirhelicopter and something
happened and they got lucky inthe fact that when they dropped,
they hit a tree and they sat inthe tree, but he ended up
(38:17):
breaking his tailbone and he hada TBI.
Okay, so he's 0%service-connected for the TBI
because of head trauma.
Head trauma again, you'reimpacting the cervical spine.
And then I talk about how he'sservice-connected for a tailbone
injury related to the crash.
So this crash was a significanttrauma to the body in general.
(38:41):
And so this veteran's story isbecause of the tailbone injury,
he had trouble sitting and hereally struggled and manipulated
his body so that he couldcontinue to fly, and all those
stressors impact the rest of thespine.
So then I go on.
(39:01):
Because they said that wedidn't talk about how we fly
medical helicopters, I said,following his military service,
the veteran has not experienceda traumatic injury, traumatic
brain injury, he has notexperienced head trauma and he
has not been involved in ahelicopter crash.
Because they want us to talkabout his post-service stuff.
Well, he didn't have ahelicopter crash after service.
(39:23):
He had it in service.
So the impact is much differentthan what we're looking at with
his current occupation.
And then I talk about how themedical helicopters are less
physically demanding compared tohis 15 years of military
service.
I said contrary to the inferencein the rating decision, the
(39:43):
veteran did not experience asudden onset of cervical spine
symptoms in March of 2022.
Instead, he woke with nervesymptoms affecting the upper
extremities.
The sudden development of nervesymptoms during sleep is
commonly observed in individualswith degenerative disc disease.
(40:04):
And then I talk about his MRI,which also supported that it
wasn't a sudden onset.
The prolonged nerve pressurecaused by sleeping position in
the presence of cervical discdisease can exacerbate the
condition.
The March 2022 report of nervesymptoms is clinically
(40:25):
consistent with an exacerbationof the veteran's cervical spine
condition.
So they're trying to argue thatyou didn't have an issue until
you woke up and had numbness inyour arm.
No issue until you woke up andhad numbness in your arm.
No, that's why you're notmedical.
That's why you're not qualifiedto write an opinion.
Well, 15 years as a helicopterpilot, cadet boxing, repelling
(41:09):
parachuting and then you get outand, like eight years after
discharge, you all of a suddenwake up suddenly with issues.
I I just on this one, the.
The takeaway from this is youneed to understand when you need
legal representation, medicalrepresentation or medical help.
In this case, when a lay personprovides a medical opinion and
(41:29):
they're not quoting a medicalexaminer, they're not issuing at
least as likely as not then youneed to argue that from a legal
perspective.
Yes, you can get the help of anexus, but you also need
somebody.
If you're willing to take thaton by yourself I don't know that
I would recommend that.
I think you need an advocate inthose cases.
But yeah, that's the takeawaytakeaway.
(42:12):
So the next one I want to talkabout I know we've got like 18
minutes left, so some of these Imight just dance around this
one here that I want to talkabout briefly is the
diverticulitis one this ratingdecision.
The first rating decision isMarch of 2024.
And the second one is June of2024.
And this is a veteran who hadmultiple dates of service and it
(42:34):
was almost consecutive For like10 years.
There was only a six-monthperiod that he was not active.
The rest of those 10 years hewas on active orders and so he
has multiple DD-214s and in thefirst rating decision they miss
two of the DD-214 service datesOkay.
(42:55):
Then on the second ratingdecision, they missed one period
of service and the one periodof service they missed was that
period that the veteran was seenfor his claimed condition.
Almost seems intentional.
(43:15):
So they excluded November 2009to January 18th of 2010.
He was seen for his claimcondition on January 16th 2010.
He was in the emergency roomseeking treatment for abdominal
(43:36):
pain, for diverticulitis.
He was on active orders and forthose 10 years he was only ever
off active orders for sixmonths.
So when they denied his serviceconnection, they're saying that
there was no treatment for thecondition in his service
treatment records.
Your service treatment recordsdo not contain complaints,
(43:58):
treatment or diagnosis fordiverticulitis or diverticulosis
.
So when we write our nexus we'resaying hey, on your rating
decision, you forgot a period ofservice and during that period
of service he was seen fordiverticulitis, a CT scan was
(44:19):
done and he was given medicationfor treatment of the condition.
So in this case he probablydidn't need a nexus letter.
He probably needed someone tosay hey, va, you missed this
period of service and, by theway, during that period of
service I was also treated forthe condition.
So from the medical examinerside of things, we're not
(44:42):
confirming the dates typically.
In this case it was becausethat he received treatment that
I was like wait a minute, whyisn't this date in here?
So as the veteran, you need tomake sure that the VA is
recognizing all periods ofservice that you have DD-214s
for.
The information that is in thatparagraph is the information
(45:06):
that is given to the C&Pexaminer.
So if they're missing a periodof service, that C&P examiner
isn't getting that period ofservice either.
Any questions on that one?
Ray Cobb (45:22):
No questions.
But it seems to me it's obvious.
You know we have still to thebest of my knowledge, we're
still doing a 94.6% denials.
So it's obvious they're lookingfor reasons to deny it, or
making up reasons for denying it, or overlooking information,
(45:45):
like in this case, that theywould not have been able to
overlook, just so that theycould continue with the denial
and say I'm going to letsomebody else make this decision
, not here in the regionaloffice, not on my watch, and I
think that's the thing we'vebeen seeing going on for
numerous years and I don't thinkthere's any end in sight to
(46:09):
that.
I think we've got to do justexactly what you're saying.
The veteran.
Unfortunately, it's ourresponsibility as a veteran to
make sure that they have all theinformation they need and when
you get a denial, make sure thatthey looked at all the
information that is in yourmedical records.
(46:30):
You can do that by gettingsomeone like you or some of the
other agents around the countryto be able to help you with that
.
And if you're, you know, ifyou're not, you got to be pretty
(46:56):
savvy, or learn to get prettysavvy in order to beat the VA at
their own game.
And the best compliment I hadwas just a few months ago, when
a patient advocate says boy, youreally know your way around the
VA.
You bet I do, you know, and soyou know.
And I told him.
I said you bet I do and I alsoknow the law, and that's one
thing that a lot of times youguys don't follow.
(47:18):
You don also know the law, andthat's one thing that a lot of
times you guys don't follow.
You don't follow the law.
Yes, absolutely, and so youknow.
There's some things guys outthere I hate to say this you
just can't do dealing with a VAlike you do any other
organization or any other group.
You have got to be involvedyourself.
(47:39):
You've got to take and make theeffort.
You or your spouse or a lovedone, such as a son or daughter,
has got to take theresponsibility, help guide you
through this and look up all theinformation and make sure that
they follow the law, because ifthey break the law, there's no
(48:00):
deputy sheriffs go to come andget them.
Yep, you got to go get them.
You got to be the deputysheriff, you got to be the
prosecutor, you got to be thejudge, and so you got to take
the time to do that, and whatyou pointed out tonight to me is
an excellent examples, everyone of them, how these denials
(48:21):
should not have ever been deniedto start with, and it's because
of a slip up, not necessarilybecause of the veteran, but
because of the VA regionaloffice, yep.
Bethanie Spangenberg (48:34):
Now the other big takeaway like.
I want for listeners to have fortonight is if you get a denial,
whatever reason they give,don't feel like you're being
singled out, don't feel likeyou're special because they hand
it out so much.
And it's absolutely ridiculousand I think the most ridiculous
(48:55):
one that I've seen is going tobe our last one that I'm going
to talk about here on earlier,and some of it really.
You know, if you're anempathetic person and you care
about people, some of these canreally just devastate you and
make you sick.
So don't feel special out there.
Ray Cobb (49:18):
If you know you got this condition, if this
condition you know happenedwhile you were in the military,
then stand up and fight andcontinue to fight until you win
your case.
It took me 11 years to win myfirst one.
I still didn't keep fighting.
I mean, I was told numeroustimes how is it that you say it,
(49:38):
john, don't poke the bear?
I was told.
Well, you've got 100%.
Why do you want more?
Because I deserve it, becausethe law says I'm entitled to it
and that's it, you know.
If you're entitled to it, getit.
If you're not entitled to it,if you don't have those
conditions, then don't pursue it.
Bethanie Spangenberg (50:00):
Alright, are we ready for the last one
here?
It?
All right.
Are we ready for the last onehere?
All right.
So I think what I want to do onthis one is I want to talk
about this veteran's historyfirst, before we get to the
(50:21):
denial.
Okay, so this is a case from2016, 2018, we got involved, and
so the service history is theveteran served in the army from
October 1999 to March of 2004.
And then again from February2008 to January of 2014.
(50:41):
So we have five, 10 years inthere, or maybe a little bit
more.
So the veteran served in combatand was diagnosed with
depression, overdose, alcoholuse and PTSD while on active
service, he was being treatedfor substance abuse associated
(51:02):
with his mental health disorderswhile on active duty In
September 2012,.
While he's on active duty, forthe depression, overdose alcohol
use, ptsd, his medicaldischarge summary states that he
was going to be evaluated forpossible suicide by psychiatry.
(51:23):
However, this was unable to bedone, so the military did a
disservice, I think, there.
At his follow-up for hishospitalization, the clinician
documented that the veteran'srecollection of events prior to
the suicide attempt the recordsdocument that the veteran went
through his army things andbegan to have a panic attack
(51:45):
triggering by triggered bymemories of combat.
So from that point on, theveteran does not recall the
events that followed, which ledto his mental breakdown.
So he's having psychotic issues.
Okay, so he has aneuropsychiatric evaluation and
while while he's in service, therecords show that he has had
(52:08):
extreme emotional turmoil and Iquote extreme emotional turmoil
that complicate his currentclinical picture.
So they can't figure out.
I think what it came down to ishe had a TBI and they couldn't
really figure out if it was TBIor if it was his mental health
issue.
But they finally decided thatit was because of his mental
health that he's having all thismemory loss and psychotic
(52:30):
issues and substance abuse.
So he was service-connected fora back condition with
radiculopathy and he was treatedby the pain clinic and he was
prescribed Percocet by the painclinic for his back pain In
March of 2014,.
(52:52):
So this is two months after hewas discharged.
A clinician documented that theywere concerned with his history
of mental illness and alcoholabuse and I outrightly told him
he is at higher risk for abuseof opioids, so we have to
tightly monitor usage.
In his compensation and pensionexam, the examiner documented
(53:17):
that he had active suicidalideation, thoughts of hurting
himself and he demonstratedavoidance of external reminders
and distressing memories.
So when a person starts todemonstrate those activities,
they're starting to drinkalcohol or use drugs because
they're trying to avoid thosememories and trying to do what
(53:39):
they can to just kind of forgetthat whole time.
Okay, so in the ratingsdecision, the rating decision
denied the widow's applicationfor benefits.
I didn't mention this, sorry.
He died from acute fentanylintoxication and let me see the
(54:05):
date on that.
That's the most important part.
Oh, the veteran died on March14th 2016 from acute fentanyl
intoxication.
That was the very next sentence.
I didn't read it.
So, yeah, so he's less than twoyears out of service, he's got
all these mental health issues,there's concerns for him using
these opioids because of hishistory of alcohol abuse, and so
(54:28):
he dies from acute fentanylintoxication and that's what is
on his death certificate isacute fentanyl intoxication.
So the VA denied the widow'sbenefits for cause of death and
this is what it says.
The death certificate showsthat the veteran died on March
14, 2016, and the cause of deathwas recorded as acute fentanyl
(54:48):
intoxication.
The US National Institute ofHealth US National Library of
Medicine website provides animportant warning for fentanyl
Fentanyl should only beprescribed by doctors who are
experienced in treating pain incancer patients.
Fentanyl should be used only totreat breakthrough cancer pain.
(55:10):
There is no medical evidence ofrecord that the veteran was
being treated for any cancer andthat is why they denied the
widow's benefits.
And that was not a medicalopinion.
That was a rater copying andpasting from a website.
That is sad.
(55:36):
What can you say?
So when we wrote this nexus, weobviously outlined what I read
to you, his history and wetalked about how, um, what the
suicidal ideation and avoidancelike he was introduced to
opioids by the pain clinic inactive service because of his
(56:02):
physical conditions.
So his introduction to opioidswhich fentanyl is an opioid it
was done by the military.
So if he has access or he canget opioids and he's trying to
self-medicate, that happens withmental health disorders
especially severe, and he hadeverything and they decided that
(56:24):
well, he doesn't have cancer sohe shouldn't have been taking
fentanyl.
Ray Cobb (56:45):
Yes, Bethany.
Have these denials?
Have they been appealed and, ifso, were they appealed?
How were they appealed?
Did they go to the board or didthey just ask for a higher
level or supplemental claim?
Bethanie Spangenberg (57:05):
So we don't get a lot of the process
if the veteran comes to usdirectly.
The opioid case came to usthrough an attorney because they
obviously were representing thewidow and needed that opinion
there.
The case on the diverticulosisthat came to us directly from
the veteran and he's going toappeal that with our medical
(57:27):
opinion, that was a recent oneso we don't have any details on
that one.
Same with the helicopter pilotwe suggested he get legal
representation and so he'sworking with a legal
representative with a nexus fromus.
And then the sleep apnea one.
This one was sent to the boardand, knowing this attorney, it
(57:51):
was one, otherwise I would haveheard from him.
And then this last one, or thefirst one that we talked about
when it comes to sleep apnea,and it talked about all these
risk factors he didn't have.
He won with the Nexus letterfrom us and he didn't have
representation on that.
Ray Cobb (58:11):
The only thing to remember right there that you
just pointed out every one ofthose cases either did or are
continuing to fight for theirdisabilities, that they deserve,
and that's the most importantthing, don't give up.
Go wherever you need to go toget the proper representation,
(58:32):
but get it done.
Bethanie Spangenberg (58:34):
And they were all to fight those.
They should have.
Every single person, everysingle veteran, every single
case that I talked about tonightand I've got more over here
that we didn't get to, theyshould have fought it.
It's ridiculous the nonsensethat the va has and the audacity
to tell the widow that becauseyour, your husband, didn't have
cancer, that you're, he's notservice connected for that.
(58:58):
I mean he had kids.
Ray Cobb (59:06):
The last one.
I don't know if you can saythis or not, but that didn't by
chance happen in Detroit,michigan, did it?
Bethanie Spangenberg (59:17):
No, but I can tell you where it did happen
and I want to say Philadelphia,philadelphia VA Regional Office
.
Okay, ray, you gotta close thisout oh okay, folks, thanks for
(59:49):
joining us.
Ray Cobb (59:49):
bethany, thanks for coming on tonight, great job.
I really enjoyed hearing allthis and, for those of you who
are listening, I think the mostimportant thing that you can get
out of this story is the cutand paste.
They don't.
Some of these guys don't evenknow what they're cutting and
pasting.
They just do it because they'veseen where it worked before.
(01:00:10):
So read it very carefully, makesure they're really talking
about your case and yoursituation.
But until next week, bethany,thanks for being with us and, on
behalf of John Stacy, this isRay Cobb saying good night and
we'll see you next week.
Bye, bye-bye, thank you.
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