Medical process help

Wolf

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Like most new here, I'm in need of some help/guidance. Normally I'd do a search for my answers (I've been a lurker for a while), but I'm a little unraveled at the moment and can't focus. I apologize in advance for not doing searches. On to my issue.

I was diagnosed with server sleep apnea in fall of 2012. It was initially just obstructive, but was "upgraded" to complex later. I had a "Fast Track" MEB that I don't think was done 100% correctly - no sleep data was provided from my machine and I didn't have much time on the machine to see if I was even responding to treatment. Then in the fall of 2013, I was DNIF'd for sleep apnea - previous med people had never gotten me a waiver and I had stopped responding to treatment. By stopped responding it is two things. 1 - I frequently rip my mask off in my sleep after ~4 hours of wearing it. 2 - still chronically fatigued; for that matter, the longer I wear the mask, the more tired I am.

Just recently a RILO was held to see if I need a full MEB. The doctor's NARSUM and my commander's letter both made it clear I was unable to perform my flying duties. Basically I am unable to perform my job. The doctor also said this was unlikely to improve and they will be submitting for a medical DQ with MAJCOM.

That said the RILO somehow came back "Return to Duty". How am I supposed to return to duty? My understanding is that I am now going to be DQ'd, have no primary AFSC as a result, and then face a RIF board (currently in an exempt AFSC). Not a good place to be. I have 10.5 years in.

My questions:

1 - This seems to be a pretty clear case (and my PCM and other doc's I've talked to expected this) for a Full MEB. How do I rebuttal the RILO? The answers I'm getting from my PEBLO is only that the doc has to do a new NARSUM with significant new information. Is this the only way? I don't know what else can be said.

2 - On the surface this looks like they are trying to use the force reduction measures to avoid the MEB. Is this legal?

3 - Should I lawyer up? I'm planning on stopping by the ADC tomorrow, but I don't know how much good/help they can or will be.

My mind is going a 100 mph and not doing so well at the moment. Any input would be greatly appreciated.
 

Wolf

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And I just realized I put this in the Air Force Regulations Forum and not the Air Force Forum.... any way to delete or move this?
 

Wolf

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So just a little worked up and not sleeping. I dug up a little information that pertains to my situation, but I'm not sure how to begin addressing it.

AFI 41-210:

4.52.5.
DAWG Screening of Initial RILO package. The PEBLO will assemble the (1) NARSUM and accompanying consults/studies; (2) current AF Form 469 (reviewed and dated by provider within 30 days prior to submission); and (3) commander‘s letter; the package will be reviewed at the DAWG meet ing. If desired by DAWG membership, the referring PCM/provider may attend to present the case and answer any questions. Categorization by the DAWG is as follows:

4.52.5.1.
MEB Recommended. It is reasonably determined the member is most likely not capable of performing the duties of his/her office, grade, rank or rating. The package is forwarded to DPAMM by the PEBLO for adjudication. The standardized cover sheet checklist must be signed by the DAWG chair stating the package is ―MEB Recommended.

4.52.5.2.
Return to Duty Recommended. Member has a condition which is listed in Chapter 5 of AFI 48-123 and/or has a potentially unfitting condition which may limit or preclude deployment, yet the member is most likely capable of performing the duties of his/her office, grade, rank or rating AND the condition(s) is/are stable, controlled, and with a low risk of sudden deterioration. The package is forwarded to DPAMM by the PEBLO for adjudication. The standardized cover sheet checklist must be signed by the DAWG chair stating the package is ―Return to Duty Recommended.

Basically the "Return to Duty" recommendation seems to be in violation of this regulation as I am reading it. I am not able to perform my flight duties is clearly stated in both the NARSUM and my commander's letter. Therefore MEB Recommended requirement is met. For the return to duty, it requires the condition to be stable and controlled. Per the NARSUM neither of those conditions are met.

Problem is (and I think it was this reg as well, I read a few tonight so I'm not sure) what AFPC says is "Final". That's also what the PEBLO's say. And AFPC appears to just have signed off on the RILO what the DAWG recommended. Again, not in accordance with AFI 41-210.

Is there any recourse to this? Or am I kind of in a bad spot?
 

Wolf

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Uhg... Not trying to bump myself... but I had the years off in my origonal post. Yeah... I'm a bit worried and not really thinking clear.

Correct time line:
Fall 2011 - diagnosed with severe sleep apnea
Spring 2012 - "Fast Track" MEB
Fall 2012 - DNIF'd due to decreased response to treatment/increased hypersomnulence
Fall 2013 - Told I was going to face an MEB
Jan/Feb 2014 - RILO held with results stated above
 

deaddebate

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Did you ever get the answers to your questions in another thread? If not, please post new questions consolidating your new status, as these posts are a bit old now.
 

Wolf

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Still haven't found the answer to my questions. The only change is that I'm full up medically DQ'd from flying as of early Feb 2014 and I had another sleep study to see if anything was being missed (only "big" findings were still severe sleep apnea, 73% sleep efficiency, O2 saturation average 88%/nadir of 83%, and 0% N3 sleep meaning no refereshing sleep as I understand it). My questions from the above haven't changed sadly - my life/future in the military are still very much in limbo. Even my leadership isn't sure whats going on or how to address it.
 

deaddebate

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Symptomatic OSA with AHI/RDI greater than 15 requires an I-RILO (MEB). The other stats are important in your treatment, but as a Technician, I'm not able to interpret them other than to say they appear very abnormal. I believe N3 is another term for REM sleep, and O2 Saturation should always stay above 90%, but that needs to be interpreted by a sleep specialist and your doctor. Do you have your Sleep Study/Polysomnogram results? Can you post the "overall" or "total" AHI/RDI levels? The Medical Standards Directory (MSD) simplifies all of this down to that single statistic, and whether you are symptomatic (which you obviously are).
Lastly, have you seen your waiver application results? Even if your local MDG knows or believes a condition will permanently DQ a patient from flying, they are nearly always obligated to request a waiver so that the MAJCOM/SG can deny it, proving the waiver was considered and evaluated beyond base level. That application is important though, as it is a fantastic source of documentation and evaluation that could be great fuel for your push for an I-RILO. Recommend you request a copy of it from your MSME and read it. Just call them and ask for a printout of your most recent waiver package from AIMWTS (pronounced am-WITS). It shouldn't take them more than 5 minutes if you go in person.
 

Wolf

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I don't have my results on me, but my AHI was 46 events per hour on my first study in 2011 with each event being about 60 seconds long. My average O2 was 92% with only 0.5 minutes spent below 88%. The study a week ago showed 36 events per hour (didn't say how long) with my average O2 at 88% and 43.5% of the time below that. My max was 92% this time. I'm not a doc/technician, but that looks like a negative trend to me (admittedly two data points doesn't amount for much). Also, N3 is the stage just prior to REM, it's the "deep sleep" stage. Normal people spend about 20% of sleep in that stage and feel rested due to time spent in N3.

As far as the DQ - I haven't seen the paperwork myself (I will try to get it Monday, have meetings today), but the waiver was submitted and deneid due to being symptomatic. MAJCOM/SG DQ'd me medically. It was after that my PCM told me that Flight Medicine approached the DAWG with this additional information and the DAWG said they weren't going to submit for another RILO since I've had two and returned to duty on both of them.

That said, I don't think the DAWG shouldn't have recommended to AFPC on the most recent one to return me to duty based off this and with this "new" (but expected) information and AFI 41-210 (as I read it) they probably should probably submit again.

I just feel like I'm stuck in a rock and a hard place with no recourse.
 

deaddebate

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Here's the applicable regulation from the Medical Standards Directory.
G4 - Airmen with severe or moderate obstructive sleep apnea (diagnostic Polysomnogram AHI or RDI greater than 15) treated with positive airway pressure (PAP).
G5 - Airmen with severe or moderate obstructive sleep apnea (diagnostic Polysomnogram AHI or RDI greater than 15) treated with non-PAP modalities (positional therapy, oral appliances, etc), who continue to have symptoms despite their treatment; or require supplemental oxygen or stimulant medication to maintain wakefulness.
G6 - Airmen with mixed or central sleep apnea, regardless of AHI or RDI values.

Notes for G4 - G6: [...] The diagnosis must be based upon a nocturnal polysomnogram and the evaluation of a provider credentialed and privileged in sleep medicine. Airmen with mild obstructive sleep apnea (diagnostic Polysomnogram AHI and RDI <=15), regardless of treatment chosen, do NOT require an Initial RILO; if using CPAP needs note on AF FORM 469 stating needs electricity at deployed location.
Read your flying waiver findings (Aero Medical Summary or AMS) and re-approach your MSME, if appropriate. I hope you're successful on Monday.
 

Wolf

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I haven't let this drop - it's just been slow trying to get a copy of my waiver package - that said, my 422 is finally updated on IMR and it says that I meet retention standards but am disqualified from my AFSC. Hopefully the AMS will have more info... but this still doesn't make sense to me.

Now, there hasn't been a new RILO since I was DQ'd - my PCM told me that the DAWG didn't want to do one since I've already've been "returned to duty" (really don't understand how since I can't perform in my Rating or as an instructor in my school house anymore, and haven't for some time now).

By the way, where can I find the Medical Standards Directory? I haven't been able to find it anywhere.
 

Wolf

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So med finally got back to me wiith my "requested paperwork is ready", but it's only my 422, 469, and 1042. Only thing I wasn't able to get through IMR was the 1042 - which does say I'm disqualified from my AFSC. Despite being disqualifed from my AFSC, the DAWG still won't recommend an MEB (they recommended Return to Duty to AFPC which concured). Apparently the DAWG won't do it because I've already've been returned to duty for this condition. Can't do my job, yet I'm returned to it. Officially DQ'd and the DAWG won't readdress my case. Any recourses? My PCM and flight med doesn't seem to know what to do either. This isn't the outcome they expected.
 

deaddebate

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By the way, where can I find the Medical Standards Directory? I haven't been able to find it anywhere.
It's now on the Medical internal server. It isn't publicly available. If you want the information for a specific diagnosis, please ask.
So med finally got back to me wiith my "requested paperwork is ready", but it's only my 422, 469, and 1042. Only thing I wasn't able to get through IMR was the 1042 - which does say I'm disqualified from my AFSC. Despite being disqualifed from my AFSC, the DAWG still won't recommend an MEB (they recommended Return to Duty to AFPC which concured). Apparently the DAWG won't do it because I've already've been returned to duty for this condition. Can't do my job, yet I'm returned to it. Officially DQ'd and the DAWG won't readdress my case. Any recourses? My PCM and flight med doesn't seem to know what to do either. This isn't the outcome they expected.
The 1042 must be physically signed by the FS and you. Ask the Flight Med clinic for a copy. Ask you PCM to DQ you on your 422. Your command can then administratively DQ you through CMS. Read AFI 10-203.
 

goldberg1

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Deaddebate,

I see that you are able to see the medical standard directory. I see my PCM in a couple days for him to begin the MEB process. Since the info was pulled out of 48-123, what does the directory state in regards to psoriasis and psoriatic arthritis?

I am an E-7, 13.5 yrs in Security Forces. I have been constantly on methotrexate and meloxicam for my conditions since Dec 2013. I am on a mobility restriction/code 31 for psoriasis impacting my wear of gear.
 
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deaddebate

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Deaddebate,

I see that you are able to see the medical standard directory. I see my PCM in a couple days for him to begin the MEB process. Since the info was pulled out of 48-123, what does the directory state in regards to psoriasis and psoriatic arthritis?

I am an E-7, 13.5 yrs in Security Forces. I have been constantly on methotrexate and meloxicam for my conditions since Dec 2013. I am on a mobility restriction/code 31 for psoriasis impacting my wear of gear.
Sorry I haven't responded to you yet. I don't check this board often. I'll look for this tomorrow.
 

goldberg1

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Thank you for looking into this for me. I just am trying to gain the knowledge I need to ensure the system does what it is suppose too.
 

deaddebate

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The potentially applicable sections of the MSD include:
P29 Psoriasis or parapsoriasis, and not controlled by treatment OR controllable only with systemic meds or UV light therapy.
K73 Arthritis due to infection associated with persistent pain and marked loss of function, with X-ray evidence, and documented history of recurrent incapacitation.
K74 Arthritis of any type of more than minimal degree, which interferes with the ability to follow a physically active lifestyle, or may reasonably be expected to preclude the satisfactory performance of duties.
As an NSAID, Mobic (Meloxicam) isn't very serious but chronic use would slightly raise interest. If your pain were controlled with that med alone, then it wouldn't be a significant concern. Methotrexate is a very substantial red flag. If you need that for your arthropathy/arthritis, you almost certainly will require an I-RILO. I've seen a few psoriatic arthropathy cases and the three biggest factors are usually:
Can the member still do his/her job without significant medical restriction?
Is the condition controlled with current medication?
Will the member require frequent (more than 2x a yr) specialty evaluation (Ortho, Endo, Hema, etc.)?
Anyway, you're not obligated to tell anybody, but a good troop would inform the chain of command. You're package likely won't be submitted to AFPC (assuming you're AD) for another 2-4 months (or longer, depending on the complexity of your case), so don't expect a quick decision. Tell your Commander that he'll need to complete a memo (the PEBLO will provide a template/example) when the MDG is nearly done with their portion for AFPC review. S/He has probably written a few over his/her command and shouldn't be anything new.
 

goldberg1

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Thank you for the information. I really appreciate it and my PCM has scheduled me for an appointment on 16 Jul 14 to conduct a full physical to begin my MEB. My PCM told me, it would take him a week to have my paperwork done after the physical to push to the DAWG.
To answer the questions:
As a Security Forces member, I am on a gear restriction for psoriasis which coded me as non-deployable. Also, I will not be able to maintain my weapon qualifications. For the psoriatic arthropathy, I have been restricted to no high impact activities and no running over 1/2 mile.
I have to have blood work conducted every 2 months to check certain levels that medication impacts, and see my Rheumatologist every 6 months.
I am considered stable with the medication. I still have some psoriasis patches and joint pain in both hands, feet and knees. The medications have reduced the pain and joint issues.
I notified my supervisor and commander as soon as I knew my PCM was looking at conducting a MEB on me.
 
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