J Basser: 0:01

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 May 2025. It's a, you know, a little rainy day, but it's pretty cool. Here in Kentucky I've got my co-host, mr Ray Cobb. How you doing, ray?

Ray Cobb: 0:20

I'm doing great. How are you on this May Day Did?

J Basser: 0:23

you get out and play with the May Day Bulls. No, no, no, I don't do things like that. To me it's not playing May Day, it's called hobble around the pole. You know we got a treat for you guys. We got a young lady that's quite regular on the show and we're going to have a big discussion tonight on certain types of denials that you receive from the VA. You know, we thought all week trying to find a nice fancy name for this show and we finally figured it out. This is Bethany Spangenberg. She is the owner, ceo and the HMFIC of Valor for Vet.

Bethanie Spangenberg: 1:01

That's the Highly Mobile Foley Instructor's Chair. Oh my gosh, Took you a minute to come up with that acronym. How?

J Basser: 1:09

are you doing girl?

Bethanie Spangenberg: 1:10

I'm good. You know, I'm actually really excited because my seedlings are sprouting and we've got lots of rain and I'm hoping that this summer we're not getting a big drought and hopefully I can have a beautiful garden. So today's a good day.

J Basser: 1:29

Get them. Missouri wonders girls, you'll be fine If you like green beans stick beans and all kinds of stuff.

J Basser: 1:37

Okay, well, it's awesome. I know we were going to touch on these denials and I guess we've been compiling some stuff and we've discussed a few of them. You know, in the process of setting up the show, and I think you got a couple of good ones there that the listeners need to listen to, because some of this stuff is it's like I don't know they're on Mars or something. I have no idea what they're doing. I don't think they do either Tell you a lot of cases.

Bethanie Spangenberg: 2:02

Yeah, it's actually pretty surprising to see some of the verbiage in the rating decisions and you know, doing what we do on a regular basis. We see a lot of rating decisions and we want to see those. So then that way we can kind of refute you know what their medical expert is saying versus. You know what we have in our reports. So we see a lot of medical opinions. We see a lot of denial letters.

Bethanie Spangenberg: 2:32

One thing too with me being a former compensation and pension examiner, I pick up on a lot of verbiage that is basically copied and pasted from examiner to examiner and I know what that's like to receive an email from your regional office to say, hey, use this verbiage. And basically every examiner is copying, pasting that into their denial opinion. And so every case that I have here today it's hopefully a learning lesson. Have here today it's hopefully a learning lesson, something that can teach veterans, veteran advocates, and use some of my frustration into a useful education moment, I guess. But I've got a whole stack of them and I kind of was just going to randomly pick one because hopefully we can get through them all, but there's quite a bit.

Bethanie Spangenberg: 3:28

And I'd like to hear some stories from you guys as well, 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 One through six.

J Basser: 3:50

See, my favorite number is no, let's not do that, let's do three.

Bethanie Spangenberg: 3:53

Three, one, two, three, all right. So one, two, three, four, five yeah, I have six, I thought I had more than that. So this one this is a case that we worked on, that we received, and this is a rating decision dated March 28th of 2024. So a little over a year ago and this veteran was applying for sleep apnea and this rating decision says that their previous denial for service connection was confirmed and continued. So, in the details of, and if you have a rating decision with you and you want to kind of follow along as we do some of these, you know, I highly encourage that, because there's certain sections of the rating decision that, as a medical examiner, we like to look at. And when we look at the rating decision, we first start with the dates of service that are recognized by the VA, because medical examiners don't go through each DD-214 to verify when your service was. We're relying on the VA to give that information to us. So that's the first thing we look at is the dates of service us. So that's the first thing we look at is the dates of service. And when we jump down to why the veteran was denied for their service connection, the VA put we requested a medical opinion of the new evidence submitted with your supplemental claim.

Bethanie Spangenberg: 5:17

The conditions of sleep apnea and post traumatic stress disorder are not medically related. The obstructive sleep apnea is a separate entity, entirety from the post traumatic stress disorder and not medically related. The obstructive sleep apnea is a separate entity, entirety from the post-traumatic stress disorder and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established and it's interesting that I started that. We started with this one because when I was at the VA and I was a compensation and pension examiner, we would receive emails of verbiage to add into the comment section of our report and sometimes it would be because new case law came out, but sometimes in hindsight it was to circumvent the rating schedule and this verbiage. If you've been denied for sleep apnea, you've probably seen this same verbiage in your denial letter, because when they say that sleep apnea is a separate entity, entirely from fill in the blank and unrelated to it, a thorough review of medical literature failed to demonstrate a causal relationship. That is all copied and pasted and, believe it or not, this was not intentional. But another rating decision that I have to discuss tonight has the same verbiage and it's completely different areas of the country. So that should be a flag. Whenever you look at your rating decision, you see that verbiage in there.

Bethanie Spangenberg: 6:54

So if we jump down to the bottom section, where they quote the medical examiner's opinion further, the medical examiner talks about what sleep apnea is and then it says quote the most common cause of sleep apnea in adults is obesity, being a male and advanced age. Okay, that was the reason why they denied this veteran. Now there's no reference to medical literature associated with this. There is no discussion about the veteran's individual case. And then the second opinion that was issued was that there was not a link found between the sleep apnea and the known toxic exposures, including, but not limited to, the veterans' deployments to Kuwait. A nexus has not been established. So that's another pattern that we're seeing. They're throwing everything against a toxic exposure-related activity or a TERA, and a lot of times the veterans aren't even claiming that way. So that's an easy way for them to say a denial.

Bethanie Spangenberg: 8:00

So if we actually look at the veterans' history, remember there's three things that why the veteran was denied that the medical examiner said. They said well, the risk factors are obesity, being a male and advancing age. So then we pull up the veteran's history and he had a sleep study done in July of 2019. At the time of his diagnosis he was 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 for sleep apnea. So the only risk factor that the CMP examiner identified that was correct was that he was a male. And so when we wrote the nexus letter, we said in July of 2019, when he had this study, the only conditions that he was known to have and diagnosed with was PTSD, vitamin D deficiency. Those are the only two things.

Bethanie Spangenberg: 9:13

So then we have to break down. Okay, why has this veteran, who is not obese, who is not advancing age, why did he develop sleep apnea? And so for this one, we decided that the evidence suggested that his sleep apnea was secondary to his PTSD. And in the bottom section of our nexus letters this is where I have the most fun is because I open up and I just kind of hammer out like everything that was incorrect and so I put on there. You know, the veteran was previously denied service connection. A previous CMP examiner provided a negative opinion, stating that obesity, being male and older age are the most common causes of sleep apnea in adults. However, this veteran does not fit the profile as he is neither obese nor of advanced age. The medical opinion lacks a discussion on this veteran's specific medical conditions and the risk factors related to sleep apnea. So when you put the medical opinion side by side, you know ours has more probative value and we're just arguing that you know the VA opinion was inadequate.

Bethanie Spangenberg: 10:16

It's insufficient, it's not accurate, it's not looking at this veteran's? Conditions. I think she's frozen or locked up.

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 you up. I don't know if it's a plug-in problem or something like that. I know you got fast enough internet. Sometimes it does that. We're still set on 720. Okay, we have folks been talking about just denials and some of the crazy stuff they come up with. You know, like you don't really. I mean, you have to have some type of medical nexus or information. Okay, let's try that again.

J Basser: 11:44

Okay, there you go. I just explained to folks that you know, if you have a denial of it like that and they give you your reasons for your denial, they have to give you a basis and a reason for the denial. And saying you're fat and go diet 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 that veteran and what the veteran's risk factors were. So they were pulling all these risk factors out of thin air, but none of them applied to the veteran a veteran. So in that case, you know, there's the only way that, in my opinion, when you're looking at seeking help from legal side or from a medical side, in my opinion the really the best avenue is to get a medical opinion in that instance.

Ray Cobb: 12:32

Bethany, I have a question for you. When I, when I went through my sleep apnea claims and everything At that time in the VA, the only medical condition that they recognized that would cause sleep apnea, and in the sleep apnea clinic at Vanderbilt, what they would state would cause it, beside the ones that you just mentioned, was a heart condition, and your heart condition is a part, if you look, according to the American Heart Association. I haven't looked at it in several years because you know I want my case so, but back oh, I'm going to say 2011, 2012, that the American Heart Association conceded that sleep apnea is a directive as results of a heart condition. So, therefore, if you had the diagnosis of steinic heart disease which I did have, and in my case I'd had open heart surgery with three blockages and a double bypass, they granted mine real quick. I actually in my records that I, when I did my claim, in my letter I stated very clearly that it was secondary to my stentic heart disease. I didn't give them a chance to look anywhere else that letter that the American Heart Association, on a given date, had declared that sleep apnea is the direct results of a heart condition or some form of a heart disorder.

Ray Cobb: 14:30

So I'm not for sure that what you're trying to do there. If there really is any medical, that would be my question what medical evidence is there that combines the two, the sleep apnea to the medical condition? Is there any test? Is there any evidence beside that garbage that they cut and paste all the time and I've seen the same thing. Matter of fact, they'll use almost the same verbiage in diabetics. You know age and weight and all that as being a diabetic, not the fact that you were sprayed with Agent Orange. But is there some direct result from 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 of the accreditation education, doing my continuing legal education, I first did not believe that there was a relationship between sleep apnea and PTSD or mental health conditions in general. When I went to a NOVA conference National Organization of Veteran Advocates there was the I always do this there was an individual there as a representative from the VA who was medical and he stood in front of 300 attorneys and said there is literature out there that connects PTSD and sleep apnea and that was like 2017, 2018. And so I at that point I was like you know, I really got to understand this thought process and what apnea? And that was like 2017, 2018. And so I at that point I was like you know, I really got to understand this thought process and what that means, and so I started digging into the literature.

Bethanie Spangenberg: 16:24

Well, now that there's more data out, there is signals in the brain waves. So when you do an in-lab sleep study and they capture the brainaves, they say that the REM sleep disruption is a significant sign for those with PTSD and they say it's like the, not the gold standard, but it's the flag of having some type of mental health disorder. Anxiety or PTSD is when the REM sleep cycles are disrupted, or PTSD is when the REM sleep cycles are disrupted. The other part is for sleep apnea, and a lot of medical teaching is segmented. They talk about the endocrine organs or they'll transition to just the cardiology organs and functions and just the lungs, but they never really talk about how those systems communicate and intertwine. So when it comes to mental health and it comes to insomnia, it comes to diseases or mental health issues that cause sleep fragmentation. What happens is that sleep fragmentation doesn't allow the quality of sleep that you need, so you're changing in and out of these sleep cycles more rapidly in order for your body to kind of catch up. And I personally watch. I have data that captures how much REM that I get, how my latency, how long it takes me to fall asleep. I look at my movement. So I have personally looked at my own data for the last year to really understand my own body and that has contributed to my understanding of mental health conditions and sleep apnea.

Bethanie Spangenberg: 18:15

The other literature that's out there talks about how musculoskeletal conditions can contribute to sleep fragmentation because of the pain, and if their pain is not well controlled, then they are having the sleep fragmentation as well. Then there's research out there that talks about the medications that are used to treat certain ailments. Those medications are preventing an individual to cycle through the different sleep stages, and it's causing, during certain sleep stages is when your body starts to relax and you're not getting the good open airway that you normally would. So when you're disrupting your normal sleep cycle, you actually have more laxity in the back of your throat and your body is not as responsive. So if you're choking or gasping for air, you're in a deeper sleep before your body starts to respond. So deeper sleep, lower oxygen and then your body finally arouses. So it's, there's a lot out there now, but like I said to start with, I, I was not sold, I was 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 it and kind of make your own mind up. That's a good, that's a good shows good character doing that, you know.

Bethanie Spangenberg: 19:43

There's also research out there too, on the VA website, that talks about PTSD and sleep apnea and the relationship between the two. So for the CMP examiners to say that they're two separate conditions in entirety and there's no relationship, they're failing to look at the literature that's out there. And the VA has literature out there on their website that says it's education for the veterans with PTSD that they should be undergoing a sleep study because of the relationship between PTSD and sleep apnea, and we use that in our reports as well.

J Basser: 20:21

Is there any. I mean say, for example, from a VA rating purpose to the situation if you rate for sleep apnea. I think it's listed in the Title 38 portfolio under that. Is it still in the lungs respiratory or did they separate it out?

Bethanie Spangenberg: 20:44

There's a lot of research out there about upper sinusitis causing sleep apnea too. It's a lot that we're seeing now because sinusitis, rhinitis being presumptive when it comes to the rhinitis what we're seeing is a lot of veterans are getting kind of a delayed diagnosis. So they may have been diagnosed with sleep apnea 10 years ago and they're just now getting the diagnosis of sinusitis and rhinitis. And when we look at those cases we really have to look at that veteran's history and understand what factors are playing a role in the sleep apnea, because if they have other primary factors, then we can't write the nexus for sinusitis causing sleep apnea.

J Basser: 21:34

So hopefully that Ray was in the talk about heart disease. I mean, I know there's a lot of folks that have sleep apnea, that have acral fibrillation and they have the strokes that are triggered by APF. You know, if you put clots in your brain, they wind up passing away because of that and basically it recalls the sleep apnea because it triggered your APF to take effect and you fired 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'll get it, but nobody here is going to get that service-connected.

Bethanie Spangenberg: 22:06

That's actually part of the workup in the clinic. If somebody has AFib, then we work them up for sleep apnea, because the sleep apnea can cause 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 already 100% 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 rate sleep apnea over asthma, and I talked to an attorney about this before. So if you're a veteran out there, that's getting one rating decision for both asthma and sleep apnea. You need to argue that, Because when I talked to the attorney about it, what they said is there's a difference, Because in the regulations there's a comma that separates the two versus a dash. So in the legal jargon that I've learned, there's a difference between a comma and a dash.

J Basser: 23:08

So you should be getting rating decisions for both. Well, put me out of my misery. All right, all you advocates and all you agents listening to this, get off the table and stack your balls up, you know, and get ready to break, because we got a game to play. 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 sleep apnea. Am I cutting out again or am I doing 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're rolling pretty good now, all right, good. So for this veteran, let's see here Okay, this is, I got them together. I knew I had more than six, anyways, okay. More than six, anyways, okay.

Bethanie Spangenberg: 24:23

So this veteran was denied for obstructive sleep apnea and he was seeking a service connection through obesity. Okay, so there is an obesity as an intermediate step which you can't get service connected for obesity, but you can get service connected through obesity and I'll talk a little bit about that. So what this veteran said is that his service-connected physical conditions caused him to become obese and then that obesity caused sleep apnea and you can get service-connected for that. And we've seen it, we've worked on them, we understand the memorandum and that's how we prepare a lot of these opinions. So for this veteran, he was 50% service-connected for depression, 10% for his left knee and 10% for his right knee and 20% for his left ankle. And in this denial okay, the examiner went through here and 11 times they said that obesity is primarily due to consuming more calories than the body burns off, which is a choice. Therefore, his sleep disorder and left ankle are not medically related. Okay, so they took the sleep disorder and the left ankle and said no, it's because you're eating more calories and the body burns off and that's your choice. So then the next time they say no, obesity is primarily due to consuming more calories than the body burns off, which is a choice, so your sleep disorder is not related to your irritable bowel syndrome. And they go on and they say individually 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 medical opinion they say this Ridiculous, ridiculous. So when you write an opinion or you get an opinion for obesity, as an intermediate step you have to state that the veteran's conditions caused them to be obese and that obesity was a substantial factor in the development of sleep apnea or whatever condition you're claiming in the development of sleep apnea or whatever condition you're claiming. And then the medical examiner has to determine if they were not obese, would they still have developed the sleep apnea or the condition that they're claiming? So for this veteran we stated the veteran's left knee, right knee, left ankle and major depression caused the veteran to become obese. Obesity is a substantial factor in the development of this veteran's obstructive sleep apnea. The veteran would not have developed obstructive sleep apnea if the veteran was not obese. So he was service-connected for multiple things that prevented him from being physically active and his depression was specifically stated, that he had difficulties with motivation and with mood and when you're trying to maintain your weight or trying to lose weight you have to be motivated, you have to be focused and able to address anything that you consume and the exercise and the pain. You have to be able to juggle all these things. And this veteran did not demonstrate that he was capable of doing those things. So in our letter, after we explain about how his physical ailments limited him and his mental health condition prevented his motivation at the bottom we kind of argue with them and we say kind of argue. I guess it says um.

Bethanie Spangenberg: 28:23

One phrase seen 11 times in the nexus report states that obesity is primarily due to consuming more calories than the body burns off, which is a choice.

Bethanie Spangenberg: 28:32

However, this phrase is not supported by medical literature and it wasn't. It's not supported by medical literature and it wasn't. It's not supported by medical literature citations and I'm unable to find medical literature to support the repeated phrase from the contract examiner. One piece of medical literature found states that many healthcare providers and patients share the belief that obesity is a product of poor lifestyle choices that are under the voluntary control of affected individuals. So I take that literature and I talk about how the veteran basically needs to have all of his ducks in a row.

Bethanie Spangenberg: 29:09

And guess what, if a veteran doesn't have his ducks in a row and he's filing for service connection, that's his prerogative. You know, he didn't ask for this mental health issue. He didn't sign up to say, well, I'm going to walk away from here being depressed and having issues after I leave service. So I just found it fascinating that the mindset and this is from 2022, this decision was. So I just find it fascinating that the mindset is that, well, you're overweight and it's your fault. So I just find it fascinating that the mindset is that, well, you're overweight and it's your fault.

Bethanie Spangenberg: 29:45

So, and no consideration of the other ailments that this individual had, did this individual diabetic? By chance? No, they had no. Their only risk factors were their 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 and then 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 Association declares that obesity is caused due to the fact that the body does not accept the insulin to which it produces and in some cases, does not accept the insulin which is my case is injected or, in your two cases, it's done by the pump and therefore you become obese and continue to grow, and which is the reason for that. That's how come? Uh, now we have oipic, which works, you know, yes, and that offsets the problem that the three of us had with our diabetes and bad insulin, or body not accepting our insulin, which causes obesity, which causes a sleep apnea, and it's, you know, everything is secondary. It might be the third secondary down 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 doctors say this. I mean they're supposed to attend some type of training to understand this. You know this. I mean they're supposed to attend some type of training to understand this. You know, and you cannot interject your personal, political or whatever views into doing your job. You need to be able to follow the rules. As a quality assurance expert, I would kick that out in a hurry. You know, because you have to go by what's listed in documentation. You know you can't just make your own, yep.

Bethanie Spangenberg: 31:58

Okay, so let's since you talked about that, let's talk about, let's see. There's one on diverticulitis that I want to talk about, let's see. Okay, let's talk about this one. So this one is a rating decision from September of 2024. And this veteran was seeking service connection for his neck condition. Okay, he served 15 years in the army as a helicopter pilot.

Bethanie Spangenberg: 32:43

Okay, so his rating decision says okay, so he submitted a private opinion by his orthopedic physician and it says the January 18th 2024 medical opinion from Dr So-and-so indicated that your degenerative disc disease of the neck originated from service in relation to parachuting repelling and an aircraft crash and over 2,200 hours flying with heavy equipment worn and constant aircraft vibration. To me that's logical. That is pretty physically intensive and doing that for 15 years, you're tearing your body up. Okay, the rating decision goes on to say this is according because we wrote a nexus letter and it says that our Valid for Vets medical expert stated that the veteran endorsed neck and back pain that continued and worsened after service. He continued to fly medical health. Oh sorry, the examiner stated that you endorsed neck and back pain that continued and worsened after service, continue to fly medical helicopters and have two or three flare-ups per year. So what we were doing was just restating the veteran's testimony in that aspect. So they use that as a reason to deny.

Bethanie Spangenberg: 34:11

Because here we go while the private medical opinions and medical literature support events that show causation of a cervical spine degeneration, the medical evidence during and following service do not support the conclusion that a chronic condition was present during or after service, lack probative value as they do not address the sudden onset of symptoms in March of 2022 or the impact of flight activities following service.

Bethanie Spangenberg: 34:44

So after this veteran got out of the military, he decided to go on and fly medical helicopters and in 2022, he woke up and he had severe pain in one of his arms. And this rating decision goes through and quotes medical records from October, from March, from December, from March, from December, and what it talks about is how this veteran would lift weights or how this veteran suddenly developed this arm pain and come to find out there was no medical opinion sought for this. This is the rater copying and pasting the notes from the medical visits and saying, well, there's not a nexus there, because you have all these other conditions and all these other treatment records that you that weren't discussed, and so then, therefore, it's, it's um, not service connected. So specifically it says the medical opinions lack probative value because they do not address the sudden onset of symptoms in march of 22 or the impact of flight activities following service. So this is a raider. Raider providing their own medical opinion to deny the veteran and for this you have a lot of practice in medicine.

Bethanie Spangenberg: 36:24

No, and originally when we saw this claim, I told the veteran that because what happens is when we write a nexus letter, we will go on and say we'll write a rebuttal if you're denied for medical reasons. So for me this was not a medical reason, this is a legal issue, because you have a non-medical person, you have a lay person creating their own medical opinion and it has no legal value. That means nothing from a legal aspect. So we weren't going to write the rebuttal and I said go talk to a representative, let us know what they say. So a couple months goes by and he comes back and he says hey, I talked to my representative. They still want a nexus letter to kind of refute you know the rating decision. And so we did, based off of the representative's request.

Bethanie Spangenberg: 37:19

So in our rebuttal I talk about the veterans, all of his veterans, all of his service connections. So during military service he participated in cadet boxing during which he sustained multiple head and facial traumas. He is currently service connected for a deviated septum attributed to facial trauma. So if you have facial trauma you're also getting the impact on your neck. So you're having the rebound and the trauma from your neck. And then I talk about how he served as a helicopter pilot, logging over 2,200 hours of flight time. In 2004, he sustained injuries during a helicopter crash while attending flight school. So they were up in their helicopter and something happened and they got lucky in the fact that when they dropped, they hit a tree and they sat in the tree, but he ended up breaking his tailbone and he had a TBI. Okay, so he's 0% service-connected for the TBI because of head trauma. Head trauma again, you're impacting the cervical spine. And then I talk about how he's service-connected for a tailbone injury related to the crash.

Bethanie Spangenberg: 38:37

So this crash was a significant trauma to the body in general. And so this veteran's story is because of the tailbone injury, he had trouble sitting and he really struggled and manipulated his body so that he could continue to fly, and all those stressors impact the rest of the spine. So then I go on. Because they said that we didn't talk about how we fly medical helicopters, I said, following his military service, the veteran has not experienced a traumatic injury, traumatic brain injury, he has not experienced head trauma and he has not been involved in a helicopter crash. Because they want us to talk about his post-service stuff. Well, he didn't have a helicopter crash after service. He had it in service. So the impact is much different than what we're looking at with his current occupation. And then I talk about how the medical helicopters are less physically demanding compared to his 15 years of military service.

Bethanie Spangenberg: 39:39

I said contrary to the inference in the rating decision, the veteran did not experience a sudden onset of cervical spine symptoms in March of 2022. Instead, he woke with nerve symptoms affecting the upper extremities. The sudden development of nerve symptoms during sleep is commonly observed in individuals with degenerative disc disease. And then I talk about his MRI, which also supported that it wasn't a sudden onset. The prolonged nerve pressure caused by sleeping position in the presence of cervical disc disease can exacerbate the condition. The March 2022 report of nerve symptoms is clinically consistent with an exacerbation of the veteran's cervical spine condition.

Bethanie Spangenberg: 40:30

So they're trying to argue that you didn't have an issue until you woke up and had numbness in your arm. No issue until you woke up and had numbness in your arm. No, that's why you're not medical. That's why you're not qualified to write an opinion. Well, 15 years as a helicopter pilot, cadet boxing, repelling parachuting and then you get out and, like eight years after discharge, you all of a sudden wake up suddenly with issues. I I just on this one, the. The takeaway from this is you need to understand when you need legal representation, medical representation or medical help. In this case, when a lay person provides a medical opinion and they're not quoting a medical examiner, they're not issuing at least as likely as not then you need to argue that from a legal perspective. Yes, you can get the help of a nexus, but you also need somebody. If you're willing to take that on by yourself I don't know that I would recommend that. I think you need an advocate in those cases. But yeah, that's the takeaway takeaway. So the next one I want to talk about I know we've got like 18 minutes left, so some of these I might just dance around this one here that I want to talk about briefly is the diverticulitis one this rating decision. The first rating decision is March of 2024. And the second one is June of 2024.

Bethanie Spangenberg: 42:29

And this is a veteran who had multiple dates of service and it was almost consecutive For like 10 years. There was only a six-month period that he was not active. The rest of those 10 years he was on active orders and so he has multiple DD-214s and in the first rating decision they miss two of the DD-214 service dates Okay. Then on the second rating decision, they missed one period of service and the one period of service they missed was that period that the veteran was seen for his claimed condition. Almost seems intentional. So they excluded November 2009 to January 18th of 2010.

Bethanie Spangenberg: 43:25

He was seen for his claim condition on January 16th 2010. He was in the emergency room seeking treatment for abdominal pain, for diverticulitis. He was on active orders and for those 10 years he was only ever off active orders for six months. So when they denied his service connection, they're saying that there was no treatment for the condition in his service treatment records. Your service treatment records do not contain complaints, treatment or diagnosis for diverticulitis or diverticulosis.

Bethanie Spangenberg: 44:03

So when we write our nexus we're saying hey, on your rating decision, you forgot a period of service and during that period of service he was seen for diverticulitis, a CT scan was done and he was given medication for treatment of the condition. So in this case he probably didn't need a nexus letter. He probably needed someone to say hey, va, you missed this period of service and, by the way, during that period of service I was also treated for the condition. So from the medical examiner side of things, we're not confirming the dates typically. In this case it was because that he received treatment that I was like wait a minute, why isn't this date in here? So as the veteran, you need to make sure that the VA is recognizing all periods of service that you have DD-214s for. The information that is in that paragraph is the information that is given to the C&P examiner. So if they're missing a period of service, that C&P examiner isn't getting that period of service 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 the best of my knowledge, we're still doing a 94.6% denials. So it's obvious they're looking for reasons to deny it, or making up reasons for denying it, or overlooking information, like in this case, that they would not have been able to overlook, just so that they could continue with the denial and say I'm going to let somebody else make this decision, not here in the regional office, not on my watch, and I think that's the thing we've been seeing going on for numerous years and I don't think there's any end in sight to that. I think we've got to do just exactly what you're saying.

Ray Cobb: 46:14

The veteran. Unfortunately, it's our responsibility as a veteran to make sure that they have all the information they need and when you get a denial, make sure that they looked at all the information that is in your medical records. You can do that by getting someone like you or some of the other agents around the country to be able to help you with that. And if you're, you know, if you're not, you got to be pretty savvy, or learn to get pretty savvy in order to beat the VA at their own game. And the best compliment I had was just a few months ago, when a patient advocate says boy, you really know your way around the VA. You bet I do, you know, and so you know. And I told him. I said you bet I do and I also know the law, and that's one thing that a lot of times you guys don't follow. You don also know the law, and that's one thing that a lot of times you guys don't follow. You don't follow the law. Yes, absolutely, and so you know.

Ray Cobb: 47:25

There's some things guys out there I hate to say this you just can't do dealing with a VA like you do any other organization or any other group. You have got to be involved yourself. You've got to take and make the effort. You or your spouse or a loved one, such as a son or daughter, has got to take the responsibility, help guide you through this and look up all the information and make sure that they follow the law, because if they break the law, there's no deputy sheriffs go to come and get them. Yep, you got to go get them. You got to be the deputy sheriff, you got to be the prosecutor, you got to be the judge, and so you got to take the time to do that, and what you pointed out tonight to me is an excellent examples, every one of them, how these denials should not have ever been denied to start with, and it's because of a slip up, not necessarily because of the veteran, but because of the VA regional office, yep.

Bethanie Spangenberg: 48:34

Now the other big takeaway like.

Bethanie Spangenberg: 48:36

I want for listeners to have for tonight is if you get a denial, whatever reason they give, don't feel like you're being singled out, don't feel like you're special because they hand it out so much. And it's absolutely ridiculous and I think the most ridiculous one that I've seen is going to be our last one that I'm going to talk about here on earlier, and some of it really. You know, if you're an empathetic person and you care about people, some of these can really 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 happened while you were in the military, then stand up and fight and continue to fight until you win your case. It took me 11 years to win my first one. I still didn't keep fighting. I mean, I was told numerous times how is it that you say it, john, don't poke the bear? I was told. Well, you've got 100%. Why do you want more? Because I deserve it, because the law says I'm entitled to it and that's it, you know. If you're entitled to it, get it. 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 one here? All right. So I think what I want to do on this one is I want to talk about this veteran's history first, before we get to the denial. Okay, so this is a case from 2016, 2018, we got involved, and so the service history is the veteran served in the army from October 1999 to March of 2004. And then again from February 2008 to January of 2014. So we have five, 10 years in there, or maybe a little bit more.

Bethanie Spangenberg: 50:48

So the veteran served in combat and was diagnosed with depression, overdose, alcohol use and PTSD while on active service, he was being treated for substance abuse associated with his mental health disorders while on active duty In September 2012,. While he's on active duty, for the depression, overdose alcohol use, ptsd, his medical discharge summary states that he was going to be evaluated for possible suicide by psychiatry. However, this was unable to be done, so the military did a disservice, I think, there. At his follow-up for his hospitalization, the clinician documented that the veteran's recollection of events prior to the suicide attempt the records document that the veteran went through his army things and began to have a panic attack triggering by triggered by memories of combat. So from that point on, the veteran does not recall the events that followed, which led to his mental breakdown. So he's having psychotic issues. Okay, so he has a neuropsychiatric evaluation and while while he's in service, the records show that he has had extreme emotional turmoil and I quote extreme emotional turmoil that complicate his current clinical picture. So they can't figure out. I think what it came down to is he had a TBI and they couldn't really figure out if it was TBI or if it was his mental health issue. But they finally decided that it was because of his mental health that he's having all this memory loss and psychotic issues and substance abuse. So he was service-connected for a back condition with radiculopathy and he was treated by the pain clinic and he was prescribed Percocet by the pain clinic for his back pain In March of 2014,. So this is two months after he was discharged.

Bethanie Spangenberg: 52:57

A clinician documented that they were concerned with his history of mental illness and alcohol abuse and I outrightly told him he is at higher risk for abuse of opioids, so we have to tightly monitor usage. In his compensation and pension exam, the examiner documented that he had active suicidal ideation, thoughts of hurting himself and he demonstrated avoidance of external reminders and distressing memories. So when a person starts to demonstrate those activities, they're starting to drink alcohol or use drugs because they're trying to avoid those memories and trying to do what they can to just kind of forget that whole time. Okay, so in the ratings decision, the rating decision denied the widow's application for benefits. I didn't mention this, sorry. He died from acute fentanyl intoxication and let me see the date on that. That's the most important part. Oh, the veteran died on March 14th 2016 from acute fentanyl intoxication. That was the very next sentence. I didn't read it. So, yeah, so he's less than two years out of service, he's got all these mental health issues, there's concerns for him using these opioids because of his history of alcohol abuse, and so he dies from acute fentanyl intoxication and that's what is on his death certificate is acute fentanyl intoxication. So the VA denied the widow's benefits for cause of death and this is what it says. The death certificate shows that the veteran died on March 14, 2016, and the cause of death was recorded as acute fentanyl intoxication.

Bethanie Spangenberg: 54:50

The US National Institute of Health US National Library of Medicine website provides an important warning for fentanyl Fentanyl should only be prescribed by doctors who are experienced in treating pain in cancer patients. Fentanyl should be used only to treat breakthrough cancer pain. There is no medical evidence of record that the veteran was being treated for any cancer and that is why they denied the widow's benefits. And that was not a medical opinion. That was a rater copying and pasting from a website. That is sad. What can you say? So when we wrote this nexus, we obviously outlined what I read to you, his history and we talked about how, um, what the suicidal ideation and avoidance like he was introduced to opioids by the pain clinic in active service because of his physical conditions. So his introduction to opioids which fentanyl is an opioid it was done by the military. So if he has access or he can get opioids and he's trying to self-medicate, that happens with mental health disorders especially severe, and he had everything and they decided that well, he doesn't have cancer so he shouldn't have been taking fentanyl.

Ray Cobb: 56:45

Yes, Bethany. Have these denials? Have they been appealed and, if so, were they appealed? How were they appealed? Did they go to the board or did they 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 us directly. The opioid case came to us through an attorney because they obviously were representing the widow and needed that opinion there. The case on the diverticulosis that came to us directly from the veteran and he's going to appeal that with our medical opinion, that was a recent one so we don't have any details on that one. Same with the helicopter pilot we suggested he get legal representation and so he's working with a legal representative with a nexus from us. And then the sleep apnea one. This one was sent to the board and, knowing this attorney, it was one, otherwise I would have heard from him. And then this last one, or the first 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 letter from 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 of those cases either did or are continuing to fight for their disabilities, that they deserve, and that's the most important thing, don't give up. Go wherever you need to go to get the proper representation, but get it done.

Bethanie Spangenberg: 58:34

And they were all to fight those. They should have. Every single person, every single veteran, every single case that I talked about tonight and I've got more over here that we didn't get to, they should have fought it. It's ridiculous the nonsense that the va has and the audacity to tell the widow that because your, your husband, didn't have cancer, that you're, he's not service connected for that. I mean he had kids.

Ray Cobb: 59:06

The last one. I don't know if you can say this 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 this out oh okay, folks, thanks for joining us.

Ray Cobb: 59:49

bethany, thanks for coming on tonight, great job. I really enjoyed hearing all this and, for those of you who are listening, I think the most important thing that you can get out of this story is the cut and paste. They don't. Some of these guys don't even know what they're cutting and pasting. They just do it because they've seen where it worked before. So read it very carefully, make sure they're really talking about your case and your situation. But until next week, bethany, thanks for being with us and, on behalf of John Stacy, this is Ray Cobb saying good night and we'll see you next week. Bye, bye-bye, thank you.