All, Sorry this is so long. I received a denial letter on a NOD that I sent to the DRO. DRO denied it based off the DBQ which the Dr at the C&P submitted, but neither the Dr or the Rater looked at my Medical records. I am unsure if this is best left to run through the normal appeals process now that the DRO denied it or could I submit the below as a CUE? I'm not sure if this meets the CUE Standard. I tried to lay out the case from start to finish with evidence. All of my enclosures are word for word out of my medical records. Do I have a case for CUE? Letters A thru K below are identical but apply to all three denial points the VA tried to make.
I respectfully request the VA to call a clear and unmistakable error on part of the September 22, 2015 DRO decision letter from the Pittsburgh Regional Office and to correct it.
In the above mentioned Decision Letter from the DRO, I was denied service-connection for Right Lower Extremity Peripheral Neuropathy. In my original claim from 01 July 2015, I requested service connection for this issue based off of multiple entries in my Service Medical Records (SMR) which the VA has on file at the Pittsburgh RO.After I received my original decision letter dated June 04, 2015, I filed a Notice of Disagreement (NOD) on August 01, 2015 and elected the DRO process on August 16, 2015.
I was given my C&P exam April 05, 2015 and service connection for Right Lower Extremity Peripheral Neuropathy was not diagnosed on the DBQ with the Doctor stating, “I had denied any right sided radialculopthy.” This is an untrue statement, as I never stated that I did not have any radialculopthy symptoms and in fact stated the opposite, because in 2002 when I ruptured my lower vertebrate I had massive amounts of pain, numbness, and tingling in my right leg from my buttocks all the way to my feet. Over the last 15 years, the pain, numbness and tingling also spread into my left leg and foot and it has been at times disabling in both legs causing me to miss work. However, my right leg was not noted on the DBQ only my left leg was noted. Both legs have been documented in my SMR’s with severe peripheral neuropathy or radialculopothy.
“A denovo review of your claim shows service connection for right lower extremity peripheral neuropathy was denied because it was not diagnosed on Thoracolumbar Spine DBQ dated 4-15-2015.There was no objective evidence of right sided radialculopthy demonstrated on examination.”
1. The Decision Letter dated September 22, 2015 states that, “Service connection may be granted for a disability which began in military service or was caused by some event or experience in Service.”Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy clearly began in military service, and was in fact caused by the ruptured discs in my lower back followed by multiple surgeries to correct those ruptured discs.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO.RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT.HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR.IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002:HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT.(DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES.HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 209: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED.DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
2. The Decision Letter dated September 22, 2015 states that, “Service connection for Right Lower Extremity Peripheral Neuropathy is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.”Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy was diagnosed multiple times, and was related to ruptured discs in my lower back with multiple back surgeries.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO.RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT.HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR.IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002:HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT.(DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES.HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 209: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED.DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
3. The Decision Letter dated September 22, 2015 states that, “Service connection for an organic disease of the nervous system may be granted on a presumptive basis if it becomes manifest to a compensable degree within a certain period after military discharge.As the medical evidence fails to show a diagnosis of Peripheral Neuropathy within the time period specified under 38 CFR 3.307, service connection on a presumptive basis must also be denied.”Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy was diagnosed multiple times, and was related to ruptured discs in my lower back with the following Discectomy surgery and five years later a back fusion.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO.RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT.HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR.IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002:HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT.(DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES.HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 2009: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED.DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
The evidence listed in my Service Medical Records clearly show a diagnosis of Right Leg Peripheral Neuropathy.
The VA's failure to consider and evaluate the evidence that the VA had in their possession manifestly altered the outcome of the decision referred to above.
Question
KansasNavy
All, Sorry this is so long. I received a denial letter on a NOD that I sent to the DRO. DRO denied it based off the DBQ which the Dr at the C&P submitted, but neither the Dr or the Rater looked at my Medical records. I am unsure if this is best left to run through the normal appeals process now that the DRO denied it or could I submit the below as a CUE? I'm not sure if this meets the CUE Standard. I tried to lay out the case from start to finish with evidence. All of my enclosures are word for word out of my medical records. Do I have a case for CUE? Letters A thru K below are identical but apply to all three denial points the VA tried to make.
I respectfully request the VA to call a clear and unmistakable error on part of the September 22, 2015 DRO decision letter from the Pittsburgh Regional Office and to correct it.
In the above mentioned Decision Letter from the DRO, I was denied service-connection for Right Lower Extremity Peripheral Neuropathy. In my original claim from 01 July 2015, I requested service connection for this issue based off of multiple entries in my Service Medical Records (SMR) which the VA has on file at the Pittsburgh RO. After I received my original decision letter dated June 04, 2015, I filed a Notice of Disagreement (NOD) on August 01, 2015 and elected the DRO process on August 16, 2015.
I was given my C&P exam April 05, 2015 and service connection for Right Lower Extremity Peripheral Neuropathy was not diagnosed on the DBQ with the Doctor stating, “I had denied any right sided radialculopthy.” This is an untrue statement, as I never stated that I did not have any radialculopthy symptoms and in fact stated the opposite, because in 2002 when I ruptured my lower vertebrate I had massive amounts of pain, numbness, and tingling in my right leg from my buttocks all the way to my feet. Over the last 15 years, the pain, numbness and tingling also spread into my left leg and foot and it has been at times disabling in both legs causing me to miss work. However, my right leg was not noted on the DBQ only my left leg was noted. Both legs have been documented in my SMR’s with severe peripheral neuropathy or radialculopothy.
“A denovo review of your claim shows service connection for right lower extremity peripheral neuropathy was denied because it was not diagnosed on Thoracolumbar Spine DBQ dated 4-15-2015. There was no objective evidence of right sided radialculopthy demonstrated on examination.”
================================================================
1. The Decision Letter dated September 22, 2015 states that, “Service connection may be granted for a disability which began in military service or was caused by some event or experience in Service.” Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy clearly began in military service, and was in fact caused by the ruptured discs in my lower back followed by multiple surgeries to correct those ruptured discs.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO. RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT. HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR. IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002: HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT. (DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES. HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 209: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED. DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
================================================================
2. The Decision Letter dated September 22, 2015 states that, “Service connection for Right Lower Extremity Peripheral Neuropathy is denied because the medical evidence of record fails to show that this disability has been clinically diagnosed.” Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy was diagnosed multiple times, and was related to ruptured discs in my lower back with multiple back surgeries.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO. RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT. HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR. IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002: HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT. (DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES. HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 209: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED. DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
================================================================
3. The Decision Letter dated September 22, 2015 states that, “Service connection for an organic disease of the nervous system may be granted on a presumptive basis if it becomes manifest to a compensable degree within a certain period after military discharge. As the medical evidence fails to show a diagnosis of Peripheral Neuropathy within the time period specified under 38 CFR 3.307, service connection on a presumptive basis must also be denied.” Enclosures a. thru k. clearly show that my claim for Right Lower Extremity Peripheral Neuropathy was diagnosed multiple times, and was related to ruptured discs in my lower back with the following Discectomy surgery and five years later a back fusion.
a. SMR dated 16 Sept 2002: PT REPORTS NUMBNESS AND TINGLING IN THE RIGHT BUTTOCKS REGION AND DOWN THE BACK OF HIS RIGHT LEG ALSO. RIGHT LOWER EXTREMITY, POINT TENDERNESS IS THE SI JOINT REGION.
b. SMR dated 17 Sept 2002: MRI SHOWS THAT HE DOES HAVE A HERNIATED DISC AT L5-S1 ON THE RIGHT. HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS IN THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX IN THE RIGHT ANKLE.
c. SMR dated 20 Sept 2002: PT NEEDS MRI OF THE LUMBAR SPINE AS ORDERED BY THE ORTHOPEDIC DOCTOR. IT NEEDS TO BE DONE TODAY AN ACUTE INJURY LOW BACK PAIN WITH RADIALCULOPATHY.
d. SMR dated 24 Sept 2002: HISTORY OF COMPLAINT -- PT DEVELOPED PAIN IN THE RIGHT LEG. THE PAIN WENT FROM THE BUTTOCKS THE WHOLE WAY TO THE LATERAL SIDE OF HIS FOOT. EXAMINATION – I THINK THIS GENTLEMAN HAS RUPTURED A LUMBAR DISC. HE HAS MARKEDLY POSITIVE LASEGUE SIGN ON THE RIGHT. (DEFINITION OF LASEGUE’S SIGN IS STRAIGHT LEG MANEUVER USED IN THE DIAGNOSIS OF LUMBROSACRAL RADIALCULOPOTHY.) HE HAS NUMBNESS ON THE BORDER OF HIS FOOT AND IS INTACT NEUROVASCULARLY OTHERWISE IN THE LOWER EXTREMITIES. HE DOES HAVE A SLIGHTLY DECREASED ANKLE REFLEX ON THE RIGHT.
e. SMR dated 26 Sept 2002: RIGHT LOWER EXTREMITY PARASTHESIAS AND PAIN.
f. SMR dated 30 Sept 2002: ON EXAMINATION TODAY HE HAS SYMPTOMS THAT ARE CLEARLY SUGGESTIVE OF THIS WITH NUMBNESS ON THE LATERAL BORDER OF HIS FOOT, A POSITIVE TENSION SIGN, AND DECREASED REFLEX ON THE RIGHT ANKLE.
g. SMR dated 08 Oct 2002: MRI OF THE LUMBAR SPINE THAT SHOWS HE HAS A PROMINENT CENTRAL DISC PROTRUSION EXTENDING TO THE RIGHT OF THE MIDLINE AND IMPINGING UPON THE RIGHT S1 NERVE ROOT. THERE IS SUBLTE RETROLISTHESIS OF L5 ON S1. HIS PHYSICAL EXAM SHOWS TENDERNESS TO THE RIGHT OF THE MIDLINE. HE DOES HAVE DECREASED ANKLE REFLEX ON THE RIGHT AND MARKEDLY POSITIVE LASEGUE SIGN.
h. SMR dated 17 Oct 2002: SURGICAL OPERATIVE PROCEDURE
i. SMR dated 16 Nov 2004: DOES PAIN RADIATE? DOWN BOTH LEGS. IS THERE NUMBNESS OR TINGLING IN ANY LIMB? YES LEFT AND RIGHT. ABNORMAL GAIT IS NOTED.
j. SMR dated 22 Mar 2005: HAS OCCAISIONAL MIDLINE LOW BACK PAIN WITH RADIALCULOPOTHY.
k. SMR dated 07 Jan 2009: THROBBING LEGS MOSTLY AT NIGHT. MULTIPLE VISITS FOR LOWER BACK PAIN AND LEG PAIN. LEG PAIN HAS WORSENED. DDX RESTLESS LEG SYNDROME, REFERRAL TO NEUROLOGY.
The evidence listed in my Service Medical Records clearly show a diagnosis of Right Leg Peripheral Neuropathy.
The VA's failure to consider and evaluate the evidence that the VA had in their possession manifestly altered the outcome of the decision referred to above.
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