dsteele713

Hey guys, thanks for the advice. As far as timelines, according to the letter I have 30 days to request a personal hearing, and 60 days to reply or submit evidence. The letter also states that they will continue with payments at the current rate if I request a hearing, but that it does run the risk of overpayment if they proceed with the reduction. I mostly already knew that, but apparently they continue payments by default as opposed to you having to ask for it explicitly. So I was surprised by the lack of detail, so I gave the VA a call at their 827-1000 number and asked for more info. Apparently there is a "narrative" letter that goes into detail about how they came to their conclusion, and the representative printed a copy and dropped it in the mail for me. He also mentioned that it may have been sent out separately, so I might already have a copy coming, but in any case I should find out soon what their reasoning is. Of course I'm surprised/pissed that the letter wasn't included with the original notification I received yesterday, but that's the VA for you. Has anyone ever done a personal hearing? I'm trying to figure out if I should request it

While reactive arthritis can be a one-time thing, it can also be chronic, and in my case it seems to be. About 2 years after the first attack (was on humira until a few months prior). I had a 2nd attack that caused some pretty severe uveitis. Really bad photophobia, couldn't look at any source of light, couldn't work because that required looking at a monitor, etc. They were able to bring it under control with a lot of steroids, and put me back on humira as well. That was the basis for the increase request. I certainly don't see how it would be a decrease. And while I do seem to do fine on the meds, if the diagnostic code doesn't consider the effects of medication (and mine, DC 5002, doesn't), then the VA can't use the beneficial effects of meds to justify a lower rating. They're supposed to rate the condition based on how it is without meds.

First things first: It wasn't a large yellow packet, it was a normal-sized white envelope with 4 pages inside, only 1 of which was actually correspondence. Is this normal for a denial/reduction? Or should I be expecting another envelope? So I posted a week back (post is here). I filed for an increase, but I got a letter from the DAV that the VA plans to reduce two of the ratings I applied for an increase on. I finally got a letter from the VA this morning. 1. Reactive Arthritis - 60% to 10% 2. Facial scar - 10% to 0% Except the letter contains no details whatsoever. The entire relevant portion is "We have reviewed medical records concerning your service-connected conditions and noted some improvement in your Systemic lupus erythematosus and Scars, head, face, or neck. Based on this evidence, we are proposing to reduce your prior evaluation of it's overall disabling effect" Then they list the percentage proposals, what the new combined rating would be (40%, xxxx that noise), what my new payment would be, and then they let me know I have 30 days to request a hearing and submit evidence. It also says "We have enclosed a copy of a rating decision for your review", but that's it. The closest thing to a rating decision is what was stated above. So how do they expect anyone to be able to respond to this? They don't actually tell you what the basis for their decision is. This experience is exactly the opposite of my first claim. VA took forever, and not only denied the increased but proposed a reduction but didn't explain why. Also, they continue to refer to it as lupus even though my claim was for reactive arthritis, my diagnosis is for reactive arthritis, etc. And looking through other cases I know it should be rated under 5009 (arthritis, other, rated as by analogy to 5002, Rheumatoid arthritis)

Actually, I think the DAV is my rep. I didn't work with them to file or submit the claim, but they helped me with the first one, and they were still listed as the rep by default when I was filing on eBenefits, so I just left it like that. I still thought they wouldn't actually be involved until about three weeks ago when I got a letter from them stating the VA actually plans to reduce (more details here). I've been meaning to call them to see if they could tell me anything else (what the basis for their decision was, etc.), but the letter said to call them once I got the official VA notification, so I assumed they didn't know all the details and needed the VA letter before they could offer any help. After reading this I'll give them a call on Monday and ask if they can access my C-file, though. Obviously I'm antsy about it; the VA recommending a decrease was totally unexpected, and it would cause some serious financial strain.

This is my 2nd claim, on the first one it was fairly straightforward FDC claim. Turnaround time was extremely quick even for an FDC. A month after I filed I had a 70% rating, which later got bumped to 80% when they finished processing it, which I think took another month.

My claim has been bouncing around the various stages for a while now. It was all the way at 'Preparation for Notification', and has moved as far back as 'Preparation for Decision'. I've tried calling the 1-800 number but wasn't really successful. Occasionally they were able to tell me things, like the fact that the examiner had received the VA's C&P exam, but that was about it. Is there someone I can talk to in order to find out where it's really at?

The 5-year requirement was specifically what I was thinking of when I said it wasn't protected. Both ratings are about 2.5 years old, so there isn't any kind of protection that I'm aware of. On the other hand, I don't see how you could make the case that my condition has improved.

I haven't gotten the actual VA letter yet, and the claim is sitting at "pending decision approval" right now, but obviously I need to start preparing immediately. Here are the details: I was diagnosed with Reactive Arthritis in service. Left knee and toes swelled up, had to use crutches because of foot pain and severely limited range of motion, etc, etc. Started taking Humira and symptoms went away. Upon separation I was granted a 60% rating for the arthritis, as well as a 20% (splenectomy), and 3 10% ratings (Jaw scar, residuals of fractured mandible, tinnitus). Combined rating was 80%. After separating I continued with my active duty humira prescription, because I separated with 6 months of healthcare. About 3-5 months after my Humira supply ran out, I had another arthritis attack, except this time it was for eye inflammation (iritis or uveitis) that lead to severe photophobia. I woke up and my eyes were already in pain, if I looked at any sources of light (room had blackout curtains) I would experience shooting pain and had to close my eyes immediately. It was also a lot more sudden than the first attack. I went to bed with my eyes being irritated but not in pain, woke up to terrible pain. In contrast, it took several weeks for the arthritis to progress to its peak, so I assumed I would have time to go to the VA if symptoms started developing again, which is why I didn't get an appointment with the VA for a new Humira prescription. In addition, reactive arthritis can be a one-time thing, and it hadn't been long enough that you could say whether it was one-time or chronic. At any rate, it took some intensive care and weeks for the symptoms to mostly subside, though it took a few months to fully subside. This attack was more incapacitating than the first one. While the first one prevented most physical activity my job was a desk job and I was still able to work. By contrast, with the photophobia I couldn't operate a computer for weeks. I was mostly stuck at home doing nothing. Based on how my condition was rated (should be 5009, rated as analogous to 5002, rheumatoid arthritis). I felt I could make the case that it qualified for the 100% criteria: "With constitutional manifestations associated with active joint involvement, totally incapacitating". So I applied for an increase on that. The other relevant increase I applied for was for the 10% rating on my jaw scar. While it hadn't gotten worse, I realized I should qualify for two of the criteria for characteristics of disfigurement "wider than 1/4 inch", and "adhered to the underlying tissue". So I applied for an increase, expecting a 30% rating. I also applied for a new rating because I take immunosupressants "constantly or near constantly" to treat my arthritis. After filing I realized I may or may not get this since it might be considered pyramiding, though I'm not sure. The rating is for how it suppresses your immune system, but I'm still learning so I don't know whether this would be pyramiding or not. Would this be in your opinion? At any rate, I received a letter from the DAV saying that the VA actually plan to decrease my ratings. They're proposing a decrease to 10% for the arthritis, and a decrease to 0% for the jaw scar. I have yet to receive the VA letter, and the current status on eBenefits is "pending decision approval", though around the time the letter is dated it was at "preparation for notification". I'm assuming that's when the DAV got notice what their plans were. The letter doesn't say anything about the request for the immunosuppressants I'm taking. I'm not sure if they hadn't made a decision yet or if they had and that letter was only notifying me of possible decreases. I'm planning to call the DAV for more details on Monday. The decreases are really confusing me. I could see being denied an increase on the arthritis rating since I was only "totally incapacitated" for maybe a week or so, but a decrease makes no sense, especially a 10% rating. For 10% they would have to be rating it for chronic residuals and not as an active process. The minimum for an active process is 20%. What could be their justification for a decrease, especially that severe? At the moment I'm not experiencing any symptoms, but 1) Reactive arthritis is periodic and the severity over time varies greatly -AND- 2) I'm currently taking Humira, so any reaction is being suppressed. As for the jaw scar I'm very confused how they could justify a decrease. It hasn't changed and was rated at 10% already. So what are they thinking here? I do have some ideas for what they're thinking: - They requested DBQs for Lupus and other auto-immune disorders, and looking at my original award letter it looks like my rating is based on the criteria for lupus, though the claim is for reactive arthritis and this would fall under DC 5009, Arthritis, other. Under the different criteria for lupus it probably wouldn't qualify for 100% because ratings are based more on frequency. In fact, lupus has a 10% rating for " Exacerbations once or twice a year or symptomatic during thepast 2 years".This might explain the 10% proposal, but if so they're using the wrong criteria. And also, why did I get a 60% rating in the first place when my initial rating was for one (very drawn out) exacerbation? - For the scar, I'm really confused. I don't remember the examiner even checking to see whether my scar was adhered to the underlying tissue. The exam was mostly centered around the arthritis discussion. 0% would have to mean she measured it at less than 1/4 inch and that it was marked as not adhered. But I don't believe she checked for adherence, and I already had another evaluation that confirmed wider than 1/4 inch. And she definitely didn't measure my scar across it's length so you couldn't say less than 1/4 at the widest. Note that neither of these ratings are protected ratings, so I understand it requires less for a decrease. Still, what the hell are they thinking, and what should I do in preparation for a response? Here's what I'm thinking so far: - Schedule an appointment with rheumatology to fill out the correct DBQ. Under the correct criteria it should be 60% at a minimum, and hopefully she decides it qualifies for 100%. Since it would be an exam done by a rheumatologist under the *correct* DBQ, compared to the exam by the C&P doctor using the wrong one, this should outweigh/overrule the 10% rating from what they have already. - Have the scar re-measured, maybe by my primary care provider. Two exams showing wider than 1/4 inch should sufice. What are your thoughts? What else should I do to get ready? Would I have a basis for a CUE since it appears I was evaluated under lupus instead of under DC 6350 for Lupus instead of under DC 5009 for Arthritis? Would the recent Shinseki court case regarding how the VA cannot consider the effects of medication unless those effects are explicitly considered in the DC be relevant in this case? The effects of medicine aren't considered under 5002, though the fact that I'm fine at the moment might be their basis for the 10% rating.

Their choice of words is confusing so I can understand why you were thinking all vets would have to pay copays now, but actually they're just changing copays for people who already pay them. It says below the chart that Priority 1 will not pay co-pays, and that the tier list only applies to priority groups 2-8. Priority 1 is all vets 50% SC or vets deemed unemployable (TDIU?). So if you weren't paying co-pays before you won't be paying them now.

I'll talk to one, though you're probably right, it's not going to happen

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