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It states that the Veteran’s PTSD symptoms and sleep disturbance differ from sleep apnea impairment, and it cites a sleep study for diagnosis. The letter disputes a prior denial, arguing the prior examiner used an improper “definitive” standard rather than at least as likely as not, and contends PTSD contributed to behaviors leading to obesity, an intermediate pathway.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sample-nexus-letter-from-dr-finnerty-for-john-doe-2/277465/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sample-nexus-letter-from-dr-finnerty-for-john-doe-2/277465.png","ImageObject",442,249,{"name":88,"@type":89},"Patrick","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-31","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What records did Todd Finnerty review in this letter?","Question",{"text":109,"@type":110},"The letter states that all records provided from the Veteran’s claims file were reviewed. It also specifies that no examination was conducted for this medical opinion.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What is the medical relationship the letter argues for?",{"text":114,"@type":110},"The letter argues that sleep apnea is secondary to PTSD with alcohol abuse, emphasizing that PTSD-driven sleep disturbance differs from sleep apnea impairment.",{"name":116,"@type":107,"acceptedAnswer":117},"Why does the author disagree with the decision denying service connection?",{"text":118,"@type":110},"The author disputes the denial, stating the prior contract examiner used an inappropriate burden of proof requiring “definitive” causation instead of at least as likely as not, and that the rationale was not properly grounded in the Veteran’s evidence and psychological science.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},277465,1790294737,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":8,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":79},549758146520,"https://ap-avatar.wpscdn.com/avatar/80002397d8c0411e94?_k=1775819394049821470","Todd Finnerty, Psy.D.  \nOhio Psychologist \\#5979 NPI: 1427266741 [www.toddfinnerty.com](www.toddfinnerty.com)  \nPsychological File Review  \nVeteran’s name: John Doe DOB: XX/XX/XXXX  \nFile \\#: XXX-XX-XXXX Report date: X/XX/XXXX  \nReviewer: Todd Finnerty, Psy.D.  \nRecords Reviewed: I have reviewed all the records provided from the Veteran’s claims file. No examination was conducted for this medical opinion; I have performed a thorough review of the Veteran’s medical history.  \nReferral Questions: The Veteran is applying for service connection for sleep apnea secondary to PTSD with alcohol abuse.  \nSleep apnea analysis: Mr. Doe experiences PTSD from his military service per his VA records. The diagnostic criteria for PTSD include two separate symptoms associated with PTSD reflecting recurrent and distressing dreams as well as sleep disturbance such as difficulty falling asleep or staying asleep or restless sleep. The chronic sleep impairment from this differs from the symptoms and impairment associated with sleep apnea. Mr. Doe is also diagnosed with sleep apnea based on his 1/23/23 sleep study from Acme Sleep Medicine.  \nI disagree with the 6/6/26 decision to deny the Veteran’s service connection for sleep apnea secondary to PTSD; the rating decision erred in finding the contract examiner’s opinion sufficient and persuasive. The contract opinion should not be considered sufficient for rating purposes and relying on it was a clear and unmistakable error. The contract examiner documented using an inappropriate burden of proof that was higher than at least as likely as not; i.e., the examiner documented requiring that the medical literature demonstrate “definitive” causation rather than at least as likely as not. Merriam Webster defines the word definite as “free of all ambiguity, uncertainty, or obscurity,” and yet this is not what the examiner’s task wasthe examiner’s task was to opine on at least as likely as not. Scientific literature tends to require 95% to 100% confidence, yet the Veteran’s burden of proof was 50% or greater (at least as likely as not) . The examiner also did not apply this same burden of proof to the laundry list of risk factors they provided in their own opinion, For example, there is no evidence of “definitive” causation that age alone or “male gender” definitely causes sleep apnea. Simply stating some evidence relates to an “association” or a correlation is not a sufficient rationale. The Veteran’s burden of proof is not 100% certainty of causation (orthe 95% or higher confidence often used in research studies), it is at least as likely as not. Rationales must relate to an analysis in this context in order to be sufficient, not a requirement of closer to 100% certainty of causation. I have evaluated the medical evidence and scientific evidence related to the Veteran’s case and his burden of proof has been met.  \nThe contract examiner opined that Mr. Doe’s sleep apnea was due to obesity, but argued that Mr. Doe’s obesity was not due to PTSD. However, the contract examiner failed to base this evidence on a sound review  \nof the psychological science. The examiner stated that weight gain is “multifactorial, and related to many factors” [sic](here the examiner’s rhetoric gets out of control as he essentially just said the same thing twice-of course multifactorial means many factors) . However, the examiner’s task was to do more than offer a vague list that was not necessarily related to the Veteran’s own medical evidence, it was to address this based on factors that appear in the Veteran’s own medical evidence (including factors such as the psychological issues which can at least as likely as not impact diet and exercise) . The examiner noted that this list of factors includes “genetics, diet choices, exercise patterns, etc.” The examiner noted “genetics” yet did not describe any specific gene or gene combination that causes obesity, nor did he identify any specific gene or gene combination that the Veteran a","cbCaiaQvpIPoLZlo","https://ap.wps.com/l/cbCaiaQvpIPoLZlo","pdf",354841,"English","# Psychological File Review\n## Records Reviewed\n## Referral Questions and Sleep Apnea Analysis\n## Disagreement With Prior Denial and Burden of Proof\n## Obesity as an Intermediate Step and Behavioral Health Link","[{\"question\":\"What records did Todd Finnerty review in this letter?\",\"answer\":\"The letter states that all records provided from the Veteran’s claims file were reviewed. It also specifies that no examination was conducted for this medical opinion.\"},{\"question\":\"What is the medical relationship the letter argues for?\",\"answer\":\"The letter argues that sleep apnea is secondary to PTSD with alcohol abuse, emphasizing that PTSD-driven sleep disturbance differs from sleep apnea impairment.\"},{\"question\":\"Why does the author disagree with the decision denying service connection?\",\"answer\":\"The author disputes the denial, stating the prior contract examiner used an inappropriate burden of proof requiring “definitive” causation instead of at least as likely as not, and that the rationale was not properly grounded in the Veteran’s evidence and psychological science.\"}]","Sample Nexus Letter From Dr Finnerty for John Doe - 2 | PDF",1789501228]