Jump to content
VA Disability Community via Hadit.com

VA Disability Claims Articles

Ask Your VA Claims Question | Current Forum Posts Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users

  • homepage-banner-2024-2.png

  • donate-be-a-hero.png

  • 0

Psoriasis 30% Rating - Nod Decision Received - Advice Wanted

Rate this question


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.

Link to comment
Share on other sites

Recommended Posts

  • 0

As far as remands are concerned I think the va should change that, so that the claim does not go back to the RO that denied it. The RO that denied it, has a vested interest to keep denying to save face. Once the claim is remanded for lack of evidence or lack of properly applying the law, it should go to a impartial place l and be processed. A seperate entity, that is set up that is not under the thumb of the va. all information that is not relevant is blocked out, so the impartial panel doesnt even know who they are deciding for. Then it goes before a judge, and if the descision made by the panel is legal, then its done. no more remands to the retards. just fair, impartial justice.

63Sierra,

I totally agree the process is flawed from the beginning.

For sufferes of Psoriasis the last thing you want to have is a full-on breakout and manifestation of the illness at anytime. In my situation believe the C&P for Psoriasis is completely weighted towards the VA's side. Here's why. Consider that I have the condition on most of my body and I am currently on a drug like Enbrel that provides outstanding results and almost completely contains your condition and it then appears minimal in the eyes of a C&P examiner.

At the point of the C&P, If you are involved in a therapy routine and it works you don't get a fair exam, you get one when your condition is at the best and the C&P examiner will only see minimal symptoms they are looking for. Because you are able to control your condition at that time, the C&P examiner will report a lesser condition than you actually have and not a honest one (I'm not saying the C&P Examiner is being dishonest). A claimant would be better to go off any therapy for 6 months and suffer so the C&P examiner would see the real status of your condition and thus give an honest account of the condition.

Like I said, the whole thing is flawed for Psoriasis patients in my opinion.

I also agree the route the reviews and appeals takes is not fair. At this point I have elected to have a in-place BVA hearling because of living overseas and lack of trust in the AMVETS office in Boston. I can't do the video version of the hearing and it is worth it to me to fly back to the US and have this hearing in person. Mainly because of the delays and clock-resets that happen at each stage of the review path. It's worth the cost of a plane ticket to make the trip and solve this thing once and for all. Can't afford to have the clock reset again and start all over.

Currently, my appeal is at the RO (Boston), the same office that made the initial decision and the same office that made the NOD decision. I highly doubt the RO will ever change their decision and hope I just go away and give up. Here's the comical and totally sad fact about the current status. The last time I contacted the VA to inquire about my case, they said the next step was the VBA for an assignment of hearing date. It was stated it would be at the RO for 760 or so days prior to being sent to the VBA in DC. One has to wonder why, the RO who has twice ruled wrong (in my opinion) should get to hold my case in limbo for another 760+ days only to just send it down to the VBA in DC for the next step.

This alone should be a crime, it is in my opinion a major example of what is wrong with the VA system. These cases (in this status) are not the ones that get reported in the news reports as being reduced. These cases just drop off the charts and sit and the public doesn't even understand the truth of the matter and how they take years to be considered. With the increase of funding and effort made by the VA , one should expect better results and performance from the effort. (Again, my opinion).

Thankfully, I'm only 48 and can (hopefully) wait them out and prevail. Another good thing is this issue should be retroactive back to my initial filing and if the ruling goes in my favor the payment would be retroactive as well.

Keep in mind, my point of disagreement is with the "OR" portion of the ruling that warrants the higher 60% rating. And the fact I have been taking the Enbrel and Stelara constantly since 2007. I think they have overlooked or disregarded this point.

Link to comment
Share on other sites

  • 0

I am in the same boat. I have been on a systemic biologic for at least a decade. Since by BVA hearing, the remand stated that a C&P be scheduled, preferably during an outbreak/flare-up. I thought this was ridiculous: am I supposed to stop taking prescribed medication and suffer in order to prove how bad the psoriasis and psoriatic arthritis really LOOK??? I have drawings and measurements documented over time to describe just how bad/swollen legs, knees, arms, etc. get during a flare-up. If the only answer is to stop taking meds to prove a point, this is an unrealistic expectation on the part of the VA. It also countermands a doctor's prescribed course of treatment in order to secure benefits which would seem to be asking the veteran to commit fraud. This is exhausting, but I have gone so far as to look for pictures that show flare-up periods in order to prove my point. We'll see how this goes when I find and submit them.

Link to comment
Share on other sites

  • 0

I was able to get the VA to award me 60% for psoriasis which was an increase from 10%. This combined with my other ratings would take me to over 100% however, the VA only assigned me a partial award of 30% for payment purposes which brought me up to 80%. In the decision it states "since there is a likelihood of improvement, the assigned evaluation is not considered permanent and is subject to future examination."

I noticed on eBenefits site that I am scheduled for a re-evaluation in 5 years. That's a long waiting period in my eyes.
Has anyone ever appealed this type decision in the past and won?
Link to comment
Share on other sites

  • 0

I was scheduled for a follow-up for another condition in 5 years - that was 8 years ago. Seems they do this for conditions rated at 100% of the condition possible rating. How did you manage to convince them to give you 60%? Were you having a break-out/flare-up during the C&P or was it due to long-term use of meds?

Link to comment
Share on other sites

  • 0

I was able to get the VA to award me 60% for psoriasis which was an increase from 10%. This combined with my other ratings would take me to over 100% however, the VA only assigned me a partial award of 30% for payment purposes which brought me up to 80%. In the decision it states "since there is a likelihood of improvement, the assigned evaluation is not considered permanent and is subject to future examination."

I noticed on eBenefits site that I am scheduled for a re-evaluation in 5 years. That's a long waiting period in my eyes.
Has anyone ever appealed this type decision in the past and won?

KREM...WOW!!!

in 2001 i got a 10% for mine and then 2 years ago i filed for an increase because i had found information on the internet about the change made in 2008 on how they rate skin disorders. In my records it states coverage on the neck shoulders, chest inner thighs and waist. so at 1 time i could be covered from my kneck to my knees and all i get is a 30. In my appeal 2 years ago they were sent pictures and still only a 30. so this amazes me that you were able to get the 60. Also in 2008 it says something about disfigurement of the head neck or face. but in my case it was never taken into consideration( i dont know why).

Link to comment
Share on other sites

  • 0

Here's an update. After waiting for 829 days for the Boston RO to certify and send my case to the BVA so I begin the wait process all over again I decided to call the RO in Boston and ask for an update on my appeal. The reply was to call the BVA who in-turn said the case was at the Boston RO and not the VA. So, I called the RO again and now the answer was no more status (in terms of days expected to wait for sending to the BVA) because I had went past the 760 day counter I had been working with. At least they were honest at this stage of the game.

So, I'm left in the dark, no update information from the RO other than to wait!

So, I went to a local Veteran's Symposium of sorts put on by my local county bringing Veteran related agencies to talk and learn about what they offered. In addition to the agencies, one of my US State Senators had a member of his team on hand to field issues and questions. So, I had an idea. Since I was totally frustrated with the RO's response and felt like I was just left hanging in the wind so to speak I thought it could not hurt to speak to my Senator and ask for any help possible.

Once I was put in touch with the right person who handles VA related issues and explained my case and problem and wait, she said she would put in a Congressional on my behalf and see how the VA would respond. The hope was to get an update on my appeal, nothing more.

After a week, I got a reply from the Senator's team, and the VA acknowledged my case looked to be overdue in terms of being certified and sent to the BVA for the next step. She stated the VA would look into why the appeal was delayed and I should expect something back on the update within 3 or so weeks.

Then, last week I got an envelope from the VA containing a copy of my C-File I had requested over 10 months ago. I thought, man this is strange how something happened based on a simple request (for the C-File) from 10+ months ago.

Next, I logged into the E-Benefits and noticed my case had been updated to some extent. Actually a great deal of change but I was very concerned because it was the case was complete at the BVA and the decision had been made and was being processed for mailing back to me. Wait, I fully expected to travel to the BVA hearing to get the opportunity to present my case before a VLJ. But no, it looked like the case was over, decision was made.

No case docket number was ever issued to me, no notice of anykind. I did notice that the case had received correspondence on 23 Mar 2015 and the decision was made on 3 Apr 2015.

I contacted the VA RO yesterday and no luck on getting the decision information over the phone.

Today I got an email from my Senator's representative along with a phone call. The case was over, decision was made.

All positive in my direction. The rating for Psoriasis was changed/increased to 60%, overall rating raised to 90%, the decision was also retroactive back to my original claim date so I had a check for the retroactive difference as well.

All in all a good day.

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...

Important Information

Guidelines and Terms of Use