foleyj

Thanks for the reply. The funny thing is when I go to the VAMC for treatment for my SCD they still bill my insurance company and they pay them. The reason I would want to get it done there is because I wouldn't have to pay the copay for my private insurance which is like 300 dollars every time I get an MRI.

I have a Non Va Physician that I see for a SCD and this Non Va Physician wants me to get an MRI, can take the order or Rx that he gave me to get this MRI to a VAMC and have it done there?

J, Saw your post and found this on another forum site and thought you may want to look into it. §17.96 Medication prescribed by non-VA physicians. Any prescription, which is not part of authorized Department of Veterans Affairs hospital or outpatient care, for drugs and medicines ordered by a private or non-Department of Veterans Affairs doctor of medicine or doctor of osteopathy duly licensed to practice in the jurisdiction where the prescription is written, shall be filled by a Department of Veterans Affairs pharmacy or a non-VA pharmacy in a state home under contract with VA for filling prescriptions for patients in state homes

Carlie thanks. I know about the worksheets, but I thought I saw a post that stated something about the VA putting out new guidelines or information to help vets private physicians when they are giving the medical opinion.

A few months back I read a post that had a link to the VA site that provided information for private physicians to be able to fill out forms for VA and use the right language, does anyone know what I am referring to and have the link? Thanks Jason

This was the original post with the background information; I am hoping that there is someone here that can help me with this. I am SCD 20% for DDD and had spinal fusion of L4-L5 on 7/8/2009. I was admitted to the hospital on 7/8/2009 and released on 7/12/2009. I was given a letter from the discharging surgeon that I would require 3 months of convalescence. I submitted a claim on 8/7/2009 for a convalescence rating of 100% for the 3 month period that I would be on convalescence. I received my decision on 1/25/2010, here is where it gets confusing. I will first post the decision and then I will point out the things that I think are confusing according the the regulation. Decision: An evaluation of 100% has been assigned effective August 7, 2009 based on surgical or other treatment necessitating convalescence. Hospital records indicate that you underwent L4-L5 laminectomy and S1 fusion, on July 8, 2009. The statement from the physician indicated that you would need a three month period of convalescence. The 20 percent is continued form November 1, 2009, first day of the month following your three month period of convalescence. The effective date of the temporary 100 percent evaluation is August 7, 2009, the date we received your claim for benefits. The effective date of reduction back to 20% is November 1, 2009 the first day of the month following your release from the convalescence period. Points of Confusion: 1. The rating decision assigned the effective date of the convalescence as 8/7/2009 which was the date the claim was received. According the 38CFR 4.30 A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a)(1), (2), or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. The effective date should be the date of hospital admission which would have been 7/8/2009, not 8/7/2009 which was the date the claim was received. 2. Even though they assigned the effective date as 8/7/2009 I was only paid for 2 months instead of the 3 months that was given by the order from the doctor. I was only paid for September and October the rating went back to 20% on November 1st. I am not sure why I was only paid for 2 months even if they had the wrong effective date. So what I need is, first for someone to look at this and make sure that I am not mistaken in my assumptions that the rating was not assigned correctly. Also if it is correct what is my next course of action? Do I file and NOD? A letter of Reconsideration? Or a CUE claim? Any help would be appreciated. Thanks Jason So I sent in another letter requesting a re-evaluation of the the claim, and again I got another decision letter explaining that I was paid for the convalescence, which again is only 3 months. I sent the last one through my VSO, so is there something, or someone else that I can contact to help me with this? Sending the letters do not seem to help because whoever is reading them is not reading the regulation that I include with it. PLEASE HELP!!!!!!!

What would your recommendation be? My understanding about a CUE claim is that it is generally, either the correct facts, as they were known at the time, were not before the Board, or the statuary and regulatory provisions extant at the time were incorrectly applied. In my particular case I would think that the regulatory provisions were not applied correctly. Specifically the assignment of the effective date, and the payment of only 2 months instead of 3 as stated by the physician.

I am hoping that there is someone here that can help me with this. I am SCD 20% for DDD and had spinal fusion of L4-L5 on 7/8/2009. I was admitted to the hospital on 7/8/2009 and released on 7/12/2009. I was given a letter from the discharging surgeon that I would require 3 months of convalescence. I submitted a claim on 8/7/2009 for a convalescence rating of 100% for the 3 month period that I would be on convalescence. I received my decision on 1/25/2010, here is where it gets confusing. I will first post the decision and then I will point out the things that I think are confusing according the the regulation. Decision: An evaluation of 100% has been assigned effective August 7, 2009 based on surgical or other treatment necessitating convalescence. Hospital records indicate that you underwent L4-L5 laminectomy and S1 fusion, on July 8, 2009. The statement from the physician indicated that you would need a three month period of convalescence. The 20 percent is continued form November 1, 2009, first day of the month following your three month period of convalescence. The effective date of the temporary 100 percent evaluation is August 7, 2009, the date we received your claim for benefits. The effective date of reduction back to 20% is November 1, 2009 the first day of the month following your release from the convalescence period. Points of Confusion: 1. The rating decision assigned the effective date of the convalescence as 8/7/2009 which was the date the claim was received. According the 38CFR 4.30 A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a)(1), (2), or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. The effective date should be the date of hospital admission which would have been 7/8/2009, not 8/7/2009 which was the date the claim was received. 2. Even though they assigned the effective date as 8/7/2009 I was only paid for 2 months instead of the 3 months that was given by the order from the doctor. I was only paid for September and October the rating went back to 20% on November 1st. I am not sure why I was only paid for 2 months even if they had the wrong effective date. So what I need is, first for someone to look at this and make sure that I am not mistaken in my assumptions that the rating was not assigned correctly. Also if it is correct what is my next course of action? Do I file and NOD? A letter of Reconsideration? Or a CUE claim? Any help would be appreciated. Thanks Jason

Yeah you would think so. I have a feeling that they just automatically just give 2 months and then hope that you just get frustrated and forget about it. I can't seem to find anyone that actually understands the rating schedule. Good luck with yours.

Hi, No I haven't heard anything yet. I contacted the VA office and spoke with the VA rep that is also my POA and she sent an email to someone she said would take care of it. I have emailed her and have not heard back from her. You might want to contact someone about this because I think that the VA is not rating this correctly. If you go back and look at § 4.30 Convalescent ratings you will see that it states A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a) (1), (2) or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. My surgery was 7/8/09 and I was released on 7/12/09. I sent the claim in and it was received on 8/6/09. So they made 8/6/09 my effective date and then began the 100% rating on Sept 1st. I sent messages to them through IRIS and the response that I got was that the VA only takes the advice of the doctors for the period of convalescence and they can determine what they think is an adequate convalescence. This is crap because if the doctors note says that you get 3 months then that is what you get. I would definitely contact your VSO or the VA office in your state. I will post something when I get an answer.

Quint thanks for the info. After more digging it seems that instead of the effective date of the claim being the day I had surgery, which was 7/8/2009, the VA applied the effective date that they received the claim which was 8/6/2009. Now I guess I have to go back and submitted an NOD and explain everything all over again.

Yes that what I would think that it would start August 1st, but in the award letter it states it is from September 1, 2009 - October 31, 2009 $3,756.00 for temporary 100% with 2 dependents. I am just wondering why it didnt start august first.

I just the regulation for this and this is what I found; A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a) (1), (2) or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. So I see where it says from the first day of the month, but it also says that the effective date is the date of admission or treatment. So this is confusing. If the effective date is the date of admission, than why isn't paid from this date? This is the date at which you become 100%.

Thanks for the info it does somewhat clear things up. The only problem with my situation is that the surgery was on 7/8/2009, so if the VA starts the rating on the 1st of the next month shouldn't it have started on the 1st of August? The other problem is that this is not mentioned anywhere in the regulation that explains the rating criteria. So would it help if I went back to my doctor and had him amend the order for my convalescence? I was actually off of work until November, I just read the regulation and told him to make it 3 months and he said if I needed more to just tell him.

Well I finally got in touch with a very helpful VA rep on the phone. I was actually surprised that this person was so helpful, but anyway here is the response that was sent to me. Now keep in mind that the original claim was for 3 months. Mr. Foley: This is in response to your inquiry dated January 29, 2010, regarding retroactive pay. Based on the notification letter, the VA granted temporary 100% for two months, September 2009 and October 2009. September 1, 2009 - October 31, 2009 $3,756.00 for temporary 100% with 2 dependents. I am trying to figure out why I was only paid for two months instead of three. The letter that I sent in from the doctor clearly states that the convalescence will be 3 months.