Ad free subscription.


This eBook will teach you how to get C-Files (paper and electronic) from the VA Regional Office.
How to Get your VA C-File




  • Topics

  • Forum Statistics

    • Total Topics
      60,115
    • Total Posts
      388,070
  • Topics

  • Posts

    • Full Knee Replacement
      First, if you  have newer x-rays from outside the VA, get them and the reports into your VA med file. The distance from the VA hospital initially is not as important as the distance to a local VA outpatient clinic. But, once you convince the clinic PCP then outside care (consult in VA speak) can be authorized, since the VAMC is farther away than 40 miles. 
    • Dro Review Processing Time
      I sent in an NOD requesting DRO review about two months ago.  Nothing appeared on ebenefits so I sent an ISIS message.   Took them 2 weeks to reply  (ignore their note that days reply would be sent in 5 workdays)   Return meggage said NOD was received but ebenefits is a little behind   Message said a letter was sent to me asking if I wanted DRO review.  Msg said ignore letter because I already asked for DRO in NOD. Here's  the killer.  Average time for DRO review    631 days
    • Code Sheet
      After reading my code sheet I saw I have one of those. I'm rated on my ankle as 5020-5271. It's also static.  To me the code sheet eases the Veterans MNF. I know what my codes are and I know that my contentions are either static or non-static.  This shoulf not be a secret to is at it is vital information. Nor should this be a huge issue to get. 
    • Auto Adaptive Reimbursement
      I'd try to get something in writing concerning changes/refusals, than, "run the flag up the pole" any way that I thought would help. Automatic transmissions are more or less standard these days, so I'd not be surprised about that.  Bureaucratic screw ups in budgets are not a valid reason for failing to provide benefits required by title 38. Looking at things from a different perspective, some vehicle options are often listed as options,even though they are really "standard". A/C and automatic transmissions are just two. Another possible go-around is that different trim levels of the same vehicle have different options as "standard". You could possibly buy a base version, and add options at extra cost, or an up trim version with the "options" already included as "standard". It may be that the VA is looking at what the "normal" buyer options are, and trying to avoid paying for them.  
    • CUE? Not using SMR?
      Yes, if they notice the CUE they can adjust on their own.  I just had the EED adjusted on my initial claims for asthma and left ankle, the rater looked at my entire record while processing my unadjudicated claim for diabetes.  He immediately file a cue and adjusted the EED.  I didn't have to do anything for the EED/CUE. However, my ED was actually a CU they started them in 98 vs. 97.  
    • C&P Exam Results, WTH is going on, Please Help!!!
      Agree with killemall. You got this Navy04, we can't wait for you to come back here and say DONE!    
    • Code Sheet
      Thanks Asknod My problem is finding out the code for the disability.?? PTSD Code has it at 9411&9435 Code for Unspecific Depresssive Disorder VA Notes from  PCP  has PTSD  As : SCT47505003  My Sleep Apnea Notes has the code as SCT 73430006, Some of these I get confused with Insurance Codes  for Insurance Purposes. Jbasser & Jerrel Cook had a blog talk radio show on these rating codes Last year some times Maybe I'll recheck the Archives Shows. I tried to look up the code for OSA but never found it. just the SCT #73430006..?  And I have a Boo-Coo List of NSC disability's/contentions.  with the SCT# at the end of them
    • Auto Adaptive Reimbursement
      Update. My friend talked to the head of prosthetics in Tucson(kristine) and she informed him that the VA will not cover some items like power options,automatic transmissions and a few others.(I can't remember the list of things he told me).These were all covered by the VA previously.
    • NOD / DRO or TARP?
      All, Thank you for the response's. Due to me posting all of my documents intermittently, there seems to be some confusion with the timeline and issues. I will attempt to run thru this chronologically and repost all documents including my 2015 decision which I had not previously posted and answer all questions. March 2009- Filed original Claim for the following issues and received results October 2009 (see 2009 - Rating Sheet below) I do not have the entire decision packet: TBI - 10 % SC Residuals, gallbladder removal - 0% SC Back Condition - declined SC Psoriasis - declined SC PTSD - declined SC / Stressor conceded as combat action badge. October 2010 - Filed NOD / DRO for PTSD March - 2011 - Appeal decision received. I never stated that PTSD was due to MST. The paragraph on page 2 of 2011Appeal decision below is just the last part of 10 pages that I cut out covering rules and US code that they sent in the letter. The actual decision starts at the bottom of that page. Results: PTSD declined - I did not submit any new evidence. Diagnosed as "adjustment disorder with mixed anxiety and depressed mood". Blamed on me worrying about my husband returning to Iraq, even though he had just returned??? October 2014  - Initiated following claims: (I had transferred to the North Texas VA and had finally began receiving treatment after being fed up with OKC VA. I live in southern Oklahoma, so its a drive for me to go to either one) PTSD - Re-open Claim. TBI - Request for increase. May 2015 -  I reported for C&P exams at the Dallas VA clinic for PTSD and TBI. I'm not sure if this is relevant, but I received a call while my husband and I were driving there stating that the TBI examiner had to leave early and they would have to re-schedule that exam. I protested because it is a 3 hour drive. They called me back 10 minutes later stating that he would conduct the exam. He seemed pissed the whole time. His notes stated that No TBI residuals were present.  This is also the exam where the PTSD screener stated "However, it should be pointed out that most of the symptoms the veteran described during today's MH examination certainly those common to a PTSD diagnosis- she also described during her 7/8/09 Initial PTSD examination, in Oklahoma City, three years PRIOR to her son's illness."  ( see 2015 C&P exam notes below) June 2015 - Latest decision received. Results (see 2015 - decision part 1 &2 below): TBI - Decreased to 0% SC PTSD - 50% SC May 2016 - Wondering what my best next COA should be? Would like to get PTSD effective date back to 2009 and get TBI increased to at least percentage it was before. I have about 50 days to file my NOD. Q&A: Berta: What did the C & P doc diagnose you with? 2009 - TBI (SC) and adjustment disorder with mixed anxiety and depressed mood (not SC) 2015 - No TBI residuals and PTSD w/ major depressive disorder.   Berta: Have you googled the doctor who did the C & P? I do not know the Doctor's name from 2009. But I have found several articles referring to a Dr. Gail Poyner who was conducting PTSD exams at OKC VA at the time. She was fired from the VA in 2010 for applying test to Veterans to see if they were malingering or faking. Her research paper can be found here: http://link.springer.com/article/10.1007%2Fs12207-010-9076-x?LI=true I would like to have my C-File to see if she conducted the evaluation.   Gastone: What did you claim as the PTSD Stressors in your 09 app for PTSD? Combat Action Badge   Gastone: The 1st Denial, discussed "No Evidence of Personal Assault," MST? No MST ever claimed. The paragraph that covers PTSD due to MST was just the last paragraph of 10 pages of regulations that they sent with the decision. Actual decision starts at the bottom of that page.   Gastone: Did you know anything about the DRO Process Requirement, for the N & M Evidence? I did. My fault I didn't send any. I was fed up with OKC VA and assumed they would send me for a new C&P exam. Stupid on my part.   Gastone: Did you ever get a copy of your 09 PTSD C & P DBQ? No, I did not. Blue button records do not go back that far. I have requested a copy of my C-File. EBenefits states that I will get it between NOV 2017 and NOV 2018.   Gastone:  Do you currently have a VA MH Psychiatrist/Psychologist that treats you on a regular basis? I was being seen at Bohnam, TX VA. After they kept switching Dr's a few times, I now just get my meds re-filled thru my family physician. My husband is active duty, so we are on tri-care prime remote. I also qualify for VA choice, but have not used it.   Gastone: Have they given you an official PTSD DX? I have a PTSD diagnosis and receive 50% SC in 2015.   Berta: Did they have the incident reports? I faxed in two incident reports. They do not show on the evidence list, but stressor was conceded with CAB.   Flores97: Email congressman for C-File. Thank You for the advice. I emailed my congressman today and reiterated the time crunch I am under.     2011 - Appeal decision.pdf 2015 - C&P exam Notes.pdf 2015 - decision part 1.pdf 2015 - decision part 2.pdf 2009 - Rating Sheet.pdf
    • Full Knee Replacement
      I just came back from the Ortho doctor in town he said I need a full knee replacement for my service connected injury after looking at past 11 years of x-rays from the VA and what he just took today. The Marine Corps. somehow don't keep x-rays after a certain period of time. The VA says they will not do one until I'm 60 years old, all they wanted to do was give me injections for the pain. What I have now is a Torn ACL and I'm running bone on bone, and my knee cap is just about gone so here is the question. I already receive 20% for my left knee, due to the past 3 surgery's. So after having the knee replacement what will I be looking at? for an increase? Does the VA have to pay for this since I live 178 miles from the Nearest VA hospital? because they are still telling me if you were injured on active duty you must go to the VA hospital even through the VA says They will not do a knee replacement until I'm 60? I already talked to two Veterans in town at the Vet center and they had the same problem but they paid for it out of their own pocket for the surgery then filed for an increase award. So far they are still waiting for the VA to answer them back. any ideals on the best route to take? I hate to get this done out in a local hospital then fine out the VA will not pay and give me an increase for the full knee replacement. Thank for any information on this subject.

  • HadIt.com Veteran to Veteran providing FREE information and community to veterans since 1997.

    I am proud that I've been able to offer all that HadIt.com has for free for 19 years and continue to do so. HadIt.com does accept contributions to help with costs we also offer paid ad free subscriptions. None of the paid options are required. The forum, the website, news site and podcast are free and will remain so. If you choose to support the site with a contribution or a subscription it is appreciated but never required. If you choose to make a contribution or purchase an ad free subscription, you can do so here. 

carlie

Help With Dc 5019 - Please

3 posts in this topic

My brain is fried right now from doing so much research so I really need some input here

The following is info from M21-1.

Does this mean that if you are already service connected for diagnostic code 5019

you should be receiving a compensable minimum of 10 percent ?

Thanks so much for your help everyone, I sure do appreciate it.

carlie

************************************************************

e. Rating Cases with DC 5013 Through 5024 Use the table below to rate cases that use DC 5013 through 5024.

If the DC of the case is … Then …

gout under DC 5017 rate the case as rheumatoid arthritis, 5002.

• 5013 through 5016, and

• 5018 through 5024 evaluate the case according to the criteria for limited motion or painful motion under DC 5003, degenerative arthritis.

Note: The provisions under DC 5003 regarding a compensable minimum evaluation of 10 percent for limited or painful motion apply to these diagnostic codes and no others.

Reference: For more information on 10 and 20 percent ratings based on x-ray findings, see 38 CFR 4.71a, DC 5003, Note (2).

Share this post


Link to post
Share on other sites







I think- they mean a minimum of 10% with both limited motion and also pain.

This claim might help you- but it is dated 1997 and I dont know if any of these regs have changed-dont think so-

http://www.va.gov/vetapp97/files3/9722700.txt

It makes the point that they rated the DC 5019 condition under the 5003 provisions.

'The veteran’s right shoulder and left shoulder disabilities

have been evaluated under Diagnostic Code (DC) 5019 for

bursitis. This Code provision states that bursitis is to be

evaluated under DC 5003 as for degenerative arthritis.

38 C.F.R. § 4.71a, DC 5019.

DC 5003 states that degenerative arthritis established by x-

ray findings will be rated on the basis of limitation of

motion under the appropriate diagnostic codes for the

specific joint involved. When however, the limitation of

motion of the specific joint or joints involved is

noncompensable under the appropriate diagnostic codes, a

rating of 10 percent is to be applied for each such major

joint or group of minor joints affected by limitation of

motion. Limitation of motion must be objectively confirmed

by findings such as swelling, muscle spasm, or satisfactory

evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. "

Share this post


Link to post
Share on other sites

Berta and all,

On my 2002 C & P, VA Doc put " insertion of the Trapezius muscle on the right is

very tender to palpation -- I think there is a rule, can't find it now but it refers to

pain on palpation and that this pain must also be considered.

How about this one here ? It just refers to 5019 evaluated at 10 %, . (I am not using this as an example of painful palpation).

http://www.va.gov/vetapp04/files2/0415517.txt

III. Compensable rating - Bursitis of the left shoulder

The veteran seeks a compensable rating for his service-

connected bursitis of the left shoulder. Disability

evaluations are based upon the average impairment of earning

capacity as contemplated by the schedule for rating

disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part

4 (2003). In order to evaluate the level of disability and

any changes in condition, it is necessary to consider the

complete medical history of the veteran's condition.

Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991).

However, where an increase in the level of a service-

connected disability is at issue, the primary concern is the

present level of disability. Francisco v. Brown, 7 Vet.

App. 55 (1994). In cases in which a reasonable doubt arises

as to the appropriate degree of disability to be assigned,

such doubt shall be resolved in favor of the veteran.

38 C.F.R. § 4.3 (2003). Where there is a question as to

which of two evaluations shall be applied, the higher

evaluation will be assigned if the disability picture more

nearly approximates the criteria required for that rating.

38 C.F.R. § 4.7 (2003).

When evaluating musculoskeletal disabilities, the Board must

also consider whether a higher disability evaluation is

warranted on the basis of functional loss due to pain or due

to weakness, fatigability, incoordination, or pain on

movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 under

any applicable diagnostic code pertaining to limitation of

motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995).

Bursitis is rated under Diagnostic Code 5019, which in turn

makes reference to Diagnostic Code 5003, for degenerative

arthritis. Diagnostic Code 5003 specifies that degenerative

arthritis of a major joint be rated under the criteria for

limitation of motion of the affected joint, with a minimum 10

percent rating assigned for such limitation. Limitation of

motion of the shoulder is rated under Diagnostic Code 5201,

which awards a 30 percent rating for motion of the arm

limited to 25º from the side, a 20 percent rating for motion

of the arm to midway between the side and shoulder level, and

a 20 percent rating for limitation of motion at the shoulder

level; these ratings apply to minor, that is, non-dominant

joints. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2003). In

every case where the requirements for a compensable rating

are not met, a zero percent evaluation may be assigned, even

if the diagnostic schedule does not provide for such a

noncompensable evaluation. 38 C.F.R. § 4.31 (2003).

According to the October 2001 VA examination report, he is

right-handed, and thus his left shoulder is a minor joint.

The Board notes that the position of an arm held out at

shoulder level is 90 degrees from the position of the arm at

the side. See 38 C.F.R. § 4.71a, Plate I (2003).

The veteran underwent VA orthopedic examination in October

2001. He reported a long history of left shoulder pain which

extends across his chest both anteriorly and posteriorly. On

objective examination, he was without edema, effusion,

redness, heat, or instability of the left shoulder joint.

However, he did report weakness and tenderness. He also had

abnormal movement and guarding of movement. Range of motion

testing of the left shoulder revealed forward flexion to

162?, abduction to 161?, external rotation to 84?, and

internal rotation to 82?. While pain, weakness, instability,

fatigability, and lack of endurance were noted, no additional

limitation of motion was attributed to these factors. X-rays

of the left shoulder revealed minor degenerative changes.

The final diagnosis was of degenerative joint disease of the

left shoulder, with loss function due to pain.

The veteran has also received VA outpatient treatment for

left shoulder pain. However, his outpatient treatment

records do not reflect any range of motion findings.

Based on the October 2001 examination findings, the veteran

does not have sufficient limitation of motion of the left

shoulder to warrant a compensable rating. According to

Diagnostic Code 5201, the veteran's left arm must be limited

to shoulder level movement in order for a compensable rating

to be warranted. However, the veteran has both forward

flexion and abduction of the left shoulder to 162º and 161º,

respectively, well in excess of shoulder level. Therefore,

the criteria for the award of a compensable rating are not

met, and a noncompensable rating must be assigned under

Diagnostic Code 5201.

However, the Board also notes that Diagnostic Code 5003,

referenced by Diagnostic Code 5019, awards claimants a 10

percent rating for each affected major joint, if the joint

does not have limitation of motion to a compensable degree,

but does have some limitation of motion. Therefore, because

the veteran has already been awarded service connection for

bursitis of the left shoulder, and has some limited and

painful motion of that joint, a 10 percent rating is

warranted for this disability under Diagnostic Code 5003.

Also considered by the Board were the provisions of 38 C.F.R.

§ 4.40 which requires proper consideration to be given the

effects of pain in assigning a disability rating, as well as

the provisions of 38 C.F.R. § 4.45 and the Court's holding in

DeLuca. However, there is no evidence in the present case

that there is any weakness, excess fatigability, or

incoordination due to flare-ups of the service-connected left

shoulder disability which would warrant increased

compensation. While the VA examiner noted in October 2001

that the veteran's left shoulder displayed pain on motion,

weakness, and tenderness, the examiner did not express this

additional impairment in terms of additional limitation of

motion. Therefore, a rating in excess of 10 percent under

38 C.F.R. §§ 4.40, 4.45 or under DeLuca is not warranted.

In conclusion, the preponderance of the evidence supports a

compensable rating of 10 percent and no higher for the

veteran's service-connected bursitis of the left shoulder.

As a preponderance of the evidence is against the award of an

increased rating in excess of 10 percent, the benefit of the

doubt doctrine is not applicable in the instant appeal. See

38 U.S.C.A. § 5107(:( (West 2002); Ortiz v. Principi, 274

F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet.

App. 49, 55-57 (1991).

specific joint involved. When however, the limitation of

motion of the specific joint or joints involved is

noncompensable under the appropriate diagnostic codes, a

rating of 10 percent is to be applied for each such major

joint or group of minor joints affected by limitation of

motion. Limitation of motion must be objectively confirmed

by findings such as swelling, muscle spasm, or satisfactory

evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. "

Edited by carlie

Share this post


Link to post
Share on other sites
Guest
This topic is now closed to further replies.