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Psoriasis 30% Rating - Nod Decision Received - Advice Wanted

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HawaiiJ

Question

Hello, I’m looking for some guidance and understanding on one of the Service Connected issues I have. I’ll apologize in advance if I get long winded but will do my best provide the timeline and decisions along the way. Here’s a simple timeline.

Jan 2009 - Retired USAF

Jun 2009 - VA Received initial VA Claim for Disability

Dec 2009 - VA Examination at the VAMC Boston

May 2010 - Notified of Decision

Apr 2011 - NOD Received at VA

Oct 2012 - NOD Decision sent to Claimant

I agree with all my SC decisions made by the VA with one exception: PSORIASIS, initially determined to be 30% disabling. My opinion based on evidence provided, it should have been 60%.

The May 2010 decision was for 30% disability for Psoriasis was based on 20% of the body and the it goes on to include all the other technical terms related to a Psoriasis decision.

The decision noted that my Psoriasis is treated with 50 milligrams of Embrel twice per week which has been effective.

The Embrel injections started in Nov 2007. This was after countless treatments with all the cream, suave & solution therapies available. It also included a two regimens of Cyclosporine which worked wonders until stopped and the Psoriasis conditions came back with a vengeance. FYI - My issue with Psoriasis date back to 1994.

The following paragraph was included in the decision as well in the initial decison:

“an evaluation of 30% is assigned from January 1, 2009. An evaluation of 30% is granted for evidence showing 20 to 40 % for the entire body or 20 to 40% of exposed areas affected, or; systemic therapy such as corticosteriods or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A higher evaluation of 60% is not warranted unless evidence shows more than 40% of the entire body or more than 40% of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period.”

That was the 30% decision and how to increase to 60% if warranted. My understanding of the decision was something had been missed on the immunosuppressive drug therapy-EMBREL. I had began taking Embrel in Nov 2007 which was nearly 18 months of use at the time I filed the initial VA Claim. Embrel is clearly described as an immunosuppressive drug on the drug manufacturers website and others related to Psoriasis info. My twice weekly injections were constant meaning this was the dosage and use prescribed by my doctor.

I felt this was a clear miss on the VA’s part. Embrel was in use for longer that the “constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period” threshold described in the VA decision.

So, I decided to file a NOD, requesting the higher 60% decision based on the use of immunosuppressive drug therapy. I’m thinking this is easy, I state the obvious, provide clear dates with evidence and should be a simple correction to the 60% rating.

Also, It should be noted between the initial decision and filing the NOD the Embrel stopped working and I began taking STELARA which also decreases and impacts your immunosuppressive system in a negative way too. All this information was provided in the NOD filing and it showed a continuous use of EMBREL and STELARA from Nov 2007 until the date of the filing. Well over the 12-month use threshold required for 60% rating. To date I’m still using STELARA and the VA is currently paying 100% the cost of this therapy via their Foreign Medical Program (VA-FMP).

On 22 Oct, 2012 the NOD decision was received the VA decision was to maintain the 30% disability rating based on the exact same reasoning listed in the original decision and also the NOD decision included the same comments about what warranted a higher 60% rating which stated: “constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period”. No progress was by filing the NOD. The VA came to the same decison without clearly stating Embrel use was involved in the decision.

Ok, thats the story here’s a few questions I need help on understanding if anyone has a recommendation. I have 60 days to make a decision to appeal, disagree or request a hearing in person.

1. What qualifies as: constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period? Does constant use as prescribed by doctor from 2007-present meet definition of constant or near-constant?

2. EMBREL and STELARA both suppress the immune system this is based on the drug information listed on the manufacturer’s sites. Why does this not meet the VA threshold for immunosuppressive therapy?

3. What am I missing?

4. Am I foolish for thinking I should be at 60%?

5. Would a BVA hearing be a mistake or am I chasing something I can’t catch?

Sorry for the long version, hopefully I have provided enough info without clouding the issue too much. Looking forward to the replies. Thanks.

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Justuluk

What are the steroids doing to your body? Do they make you gain weight? I know you want to keep working and I don't blame you. Immune suppressive drugs scare me, but I guess if you are very careful it is OK since the alternative is not good. Does untreated PsA totally cripple a person? Can't they just do a blood test to see if you have it at the VA? It seems you face a risk either way.

John

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Justuluk

What are the steroids doing to your body? Do they make you gain weight? I know you want to keep working and I don't blame you. Immune suppressive drugs scare me, but I guess if you are very careful it is OK since the alternative is not good. Does untreated PsA totally cripple a person? Can't they just do a blood test to see if you have it at the VA? It seems you face a risk either way.

John

John -

Thanks for the questions. PsA doesn't show up on a blood test like RA. It shows up on x-rays and other obvious physical manifestations (swelling, joint problems, etc.). I use prednisone, leuflonomide daily and humira every other week (40mg injections). The rough part is when I get sick. This happens quite a bit and when it does, I can't take the immunosuppressives as they both complicate the respiratory issues as well as increase your risk of serious illness. I've been off my normal schedule for over two weeks and am starting to swell all over. Pain increases, neck hurts worse, and so on...

Usually I end up on antibiotics and more steroids. My issue is that I'm running out of sick leave and am running out of vacation as well.

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Yes Appeal,

I don't think you are misunderstanding the rating schedule. You are and have been on an immunosuppresive. The disconnect is that the rater and VA clinician probably don't understand you are on an immunosuppresive. We often make the mistake that we assume the VA understands the information that is contained in our medical files. From the rater viewpoint, if the doctor didn't stipulate you were on immunosuppresive therapy, you wern't. If your C&P was done by a specialist they probably didn't think it important to spell out you were on immunosuppresive therapy because from thier point a view the medication is that indication. It is almost a classic catch 22.

Its kinda like the VA telling me increased urinary freaquency is not related to a side effect of the diuretic I am perscribed for my SC hypertension. Which is factually correct since increased urine clearance is the primary goal of the Diuretic....

I am confident you will prevail on appeal to the BVA. Just curious did they do a C&P during the DRO review? Did you request a DRO hearing? Or was this an appeal straight to the BVA and this is just the SOC and no Denovo review was requested?

Best regards,

71M10,

On both the initial and NOD decisions Embrel use was noted and it was stated in the decision I received. I whole heartedly believe both the Embrel and especially Stelara are relatively new in a sense that the decision makers have not seen thousands of cases where these 2 drugs are being used. I don't believe they know the drugs Embrel or Stelara are automatically linked to immunosupressive therapy unless the C&P exam report spells it out.

There was no DRO, just straight to the BVA hearing.

I really find it comical the VA is actually paying for my injections of Stelara but seem to miss this when it comes time to decide if I'm taking immunosuppressive drugs therapy. It is expensive, about $ 8600 every 12 weeks. I'm getting reimbursed via the VA's FMP program with no questions so far. I front the cost, then get reimbursed prior to taking the next injection.

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HawaiiJ -

What was your resolution (if any yet) on this issue? Have you had any updates?

Thanks!

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HawaiiJ -

What was your resolution (if any yet) on this issue? Have you had any updates?

Thanks!

I got curious last week and called them to check on a couple of things. In E-benefits they still have "AMVETS" as my POA even though the POA had been revoked in Dec 12, they said I had no POA and it would just show the last POA info I had until I eleceted to have another POA. I asked about the leadtime on cases similar to mine (waiting for BVA docket date to be assigned. The reply was 710 days precisely which I find comical as to how they can predict it down to a specific number of days. I asked for specification of calendar or work days and I was told calendar days.

I just tried to get a copy of my overall timeline and had another comment but the EBenefits website is not working well and I can't access my appeal information.

I'll try again in a bit and post it and comment further on what I think about my next move (not that I really have one) other than sit and wait for the 710 days to roll around.

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The Ebenefits site is working again and here's my timeline below. Last week when I contacted the VA, I was told the normal number of days for my type of appeal is currently at 710 calendar days to get onto the BVA docket. I have no idea which date the VA used to start counting, any one know the correct answer by chance? I'm assuming the last date plus 710 days maybe?

The last time I was counting days with the VA they busted the "Calendar" day count and conveniently turned the story around and said it was work days not calender days. Who knows when my appeal will come up for BVA assignment.

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