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New C&p Ordered


I just received a letter this weekend that the Cleveland VARO has ordered 3 C&P exams.

A little background first.

10/2010 - Submitted TDIU claim

11/2010 - General C&P exam & Mental health C&P

04/2012 - Received Rating increase decision, which was automaticaly filed by VA when filing TDIU. Total rating stayed the same (70%), but was lowered on my back without a ROM exam even the C&P Doc put measurements in my exam results, which is the main reason for my NOD letter above. TDIU deferred.

04/2012 - TDIU deferred status goes back to gathering evidence phase.

08/2012 - NOD sent. See my profile for sample letter I sent disagreeing with general C&P that was performed in 11/2010.

01/2013 - VA acknowledges my NOD & I selected a DRO to review it.

01/2013 - VA requests new C&P exams.

What can I do to guard against the VA using the C&P as the sole weight when deciding my claim? I hope this C&P doc is a good one & doesn't lie like the last one. It was a good thing he didn't perform the last C&P according to VA regs or it would of been my word vs his. Can I record the C&P? If yes, do I have to let the doc know I'm voice recording the C&P? I have the general C&P tomorrow, then another mental health & then a TBI next week. I hope they get it right this time, because I don't know how much more I can take of this! Any help is greatly appreciated!



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6 answers to this question

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when a veteran submits a TDIU claim, it is a claim for an increase. I would obtain another IMO that supports your claim. Now would be a good time to do this while your claim is back in the gathering evidence (development) phase.

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In regards to recording C&P exams:

SSGmajik hoping the latest C&P examiner will be fair and do things right this time.....please let us know how it goes for you.

Edited by USMC5811

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Thank you for the help! I had my exam today & it was long, 4 hrs to be exact! I could tell this doc was new to doing C&P's, b/c he had to ask 2 other dr's for opinions on different things, but overall I was happy that he at least listened to me & was very thorough on the exam. I have to go next week for 2 more C&P's, so I'll get a copy & see what he wrote. Thanks again for the help!

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Good to hear SSGmajik. Hope when you obtain the copy of the C&P report he was thorough in filling out the paperwork and it is favorable for you.

how do u get a copy of your C&P

Hollis to get a copy of your C&P you can:

If the C&P was performed at a VA facility by a VA doc/np etc - wait at least a few days after having the exam (to give them time to write up their report) then go to the release of information desk to sign a release form to obtain a copy directly from that facility OR sometimes (not all VA clinics will do this) you can obtain one from the VA clinic that you go to after signing a release.

If the C&P was performed by a contractor (QTC etc) of the VA - you will have to wait until QTC sends it to VA which can take anywhere from 1 week to 2 months or longer. Once VA is in receipt of it (depending on RO sometimes you can check on ebenefits to see if they are in receipt of it) then you can request a copy by writing a letter to your RO. If your requesting one from your RO...I would suggest on the outside envelope on the bottom left or right hand corner to write "Privacy Act Information Request" so that the VA mail room sorts it correctly.

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               Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
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             c. Indicate nerve roots involved: (check all that apply)
                [X] Involvement of C8/T1 nerve roots (lower radicular group)
                    If checked, indicate:  [ ] Right   [ ] Left   [X] Both
             d. Indicate severity of radiculopathy and side affected:
                Right: [ ] Not affected   [ ] Mild   [X] Moderate   [ ] Severe
                Left:  [ ] Not affected   [ ] Mild   [X] Moderate   [ ] Severe
          8. Ankylosis
          Is there ankylosis of the spine? [ ] Yes   [X] No
          9. Other neurologic abnormalities
          Does the Veteran have any other neurologic abnormalities related to a
          cervical spine (neck) condition (such as bowel or bladder problems due to
          cervical myelopathy)?
          [ ] Yes   [X] No
          10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
          a. Does the Veteran have IVDS of the cervical spine?
             [X] Yes   [ ] No
          b. If yes to question 10a above, has the Veteran had any episodes of acute
             signs and symptoms due to IVDS that required bed rest prescribed by a
             physician and treatment by a physician in the past 12 months?
             [ ] Yes   [X] No
          11. Assistive devices
          a. Does the Veteran use any assistive device(s) as a normal mode of
             locomotion, although occasional locomotion by other methods may be
             [ ] Yes   [X] No
          b. If the Veteran uses any assistive devices, specify the condition and
             identify the assistive device used for each condition:
             No response provided.
          12. Remaining effective function of the extremities
          Due to a cervical spine (neck) condition, is there functional impairment of
          an extremity such that no effective function remains other than that which
          would be equally well served by an amputation with prosthesis? (Functions of
          the upper extremity include grasping, manipulation, etc.; functions of the
          lower extremity include balance and propulsion, etc.)
          [ ] Yes, functioning is so diminished that amputation with prosthesis would
              equally serve the Veteran.
          [X] No
          13. Other pertinent physical findings, complications, conditions, signs,
              symptoms and scars
          a. Does the Veteran have any other pertinent physical findings,
             complications, conditions, signs or symptoms related to any conditions
             listed in the Diagnosis Section above?
             [ ] Yes   [X] No
          b. Does the Veteran have any scars (surgical or otherwise) related to any
             conditions or to the treatment of any conditions listed in the Diagnosis
             Section above?
             [ ] Yes   [X] No
          c. Comments, if any:
             No response provided.
          14. Diagnostic testing
          a. Have imaging studies of the cervical spine been performed and are the
             results available?
             [X] Yes   [ ] No
                 If yes, is arthritis (degenerative joint disease) documented?
                 [X] Yes   [ ] No
          b. Does the Veteran have a vertebral fracture with loss of 50 percent or
             of height?
             [ ] Yes   [X] No
          c. Are there any other significant diagnostic test findings and/or results?
             [X] Yes   [ ] No
                 If yes, provide type of test or procedure, date and results (brief
                    9/25/2014,MRI Cervical spine:Visibility of the central canal of
                    cord at the C5 level with diameter of 2mm, not considered to
                    reflect significant syringohydromyelia and not associated with
                    or abnormal enhancement.  Spondylosis and degenerative disc
                    of the cervical spine.  Right-sided predominant disc osteophyte
                    complex at C6-7 causes mild right central canal and moderate right
                    neural foraminal stenosis at this level.  No other central canal
                    stenosis with milder areas of neural foraminal encroachment
                    detailed above.  C2-3:Focal shallow central to right paracentral
                    disc protrusion.  No central canal or neural foraminal stenosis.
                    C3-4:Mild generalized disc bulge.  Mild right than left neural
                    foraminal stenosis with central canal patent.  C6-7:Mild
                    generalized disc bulge with more focal disc osteophyte complex in
                    the right paracentral, right subarticular, and right lateral
                    stations.  C7-T1:Negative for disc herniation.
                    8/14/2012, MRI Cervical spine:Herniated disk C3/4, C5/6, and C6/7
                    levels.  Bulging disk C2/3 and C4/5 levels.  Diffuse spondylitic
                    changes.  Straightened alignment suggesting muscle spasm.  Focal
                    area of cord contusion or compression myelomalacia at C5 level.
          15. Functional impact
          Does the Veteran's cervical spine (neck) condition impact on his or her
          ability to work?
          [X] Yes   [ ] No
              If yes, describe the impact of each of the Veteran's cervical spine
              (neck) conditions, providing one or more examples:
                Veteran is capable of limited lifting, carrying, and bending.
          16. Remarks, if any:
              NOTE:Veteran performed neck flexion repeition which reduced ROM to
               Unable to perform any further repetition for other ROM maneuvers.
              Additional exam request information:
              For any joint condition, examiners should test the contralateral joint,
              unless medically contraindicated, and the examiner should address pain on
              both passive and active motion, and on both weightbearing and non-
              In addition to the questions on the DBQ, please respond to
              the following questions:
              1.      Is there evidence of pain on passive range of motion testing?
              2.      Is there evidence of pain when the joint is used in non-weight
              bearing? YES


                                       Medical Opinion
                              Disability Benefits Questionnaire
          Name of patient/Veteran: 
          ACE and Evidence Review
          Indicate method used to obtain medical information to complete this
          [X] In-person examination
          Evidence Review
          Evidence reviewed (check all that apply):
          [X] VA e-folder (VBMS or Virtual VA)
          [X] CPRS
          Evidence Comments:
            BOARD REMAND
          a. Opinion from general remarks: (a)  Please state all diagnoses as to the
          Veteran's cervical spine, and
          address all diagnoses already of record: herniated disk and bulging disk
          of the cervical spine and spondylitic changes, muscle spasm and
          contusion/compression, spondylosis and degenerative disc disease of the
          cervical spine, mechanical cervical pain syndrome and radiculopathy. 
          (b)  Please provide an opinion as to whether it is at least as likely as
          not (a 50 percent or greater probability) that any diagnosed cervical
          spine disability was caused by or etiologically related to active duty. 
          Please specifically address the back injuries and complaints of back pain
          noted in the STRs.
          (c)  Please specifically address the Veteran's lay statements that he has
          suffered cervical spine pain since service, and that in service he
          suffered injury to his neck while carrying heavy equipment and continuous
          wear of duty gear.
          (d)  Please address the conflicting evidence of record and offer a
          clarifying opinion, notably the February 2013 VA examination positing a
          negative nexus, and the April 2016 private opinion positing a positive

          b. Indicate type of exam for which opinion has been requested: NECK
          CONNECTION ]
          a. The condition claimed was at least as likely as not (50% or greater
          probability) incurred in or caused by the claimed in-service injury, event
          c. Rationale: Upon review of all available medical evidence, including
          virtual VA, and Board Remand, the following pertinent information is
          and reported in 'Evidence Comments': Prior VA Examination, 6/25/96, reports
          Mr. served in the Marine Corps.  he was inducted in 1990 and
          received separation with an honorable discharge in 1996.    Medical History-In 1992, he
          had onset of pain in the neck area diagnosed at Quantico.  Xrays were
          negative.  Impression was muscle spasm and stress. Enlistment RME/RMH for
          national guard, 4/13/98, reported no neck problems and normal exam of the
          spine.  Miami VAMC, Outpatient clinic, 5/6/2005:Assessment is chronic neck
          and low back pain-Will get plain films and MRI, does not want any meds.
          2/28/2013, VA examination opines "Unable to find SMR evidence of significant
          neck injury or complaint in service.  No evidence to support chronicity of
          problem for over 10 years post-discharge."  THIS OPINION IS GIVEN LOW WEIGHT
          neck was completed providing a diagnosis of mechanical cervical pain
          and radiculopathy. As received 4/8/16, VA physician, ,
          states that the Veteran suffers from cervico-occipital neuralgia and
          radiculopathy with bulging disc "are as likely as not a direct result of
          blunt trauma received during the patient's military career.  His conditions
          are a severe occupational impairment to the veteran and has been exacerbated
          by many years of continuous wear of duty gear related to his profession." 
          today's C&P examination, 11/21/17, Veteran is a credible historian and
          reports several incidents in 1992-1995 of blunt trauma, involving ground
          defensive tactic also known as "Bull in the Ring" in which the marine is in
          full gear and is potentially tackled by several marines.  Following this ,

          Veteran incurred concussion-1992 or 1993).  Veteran also reported chronic
          neck pain during service was due to carrying 50 caliber machine gun barrels
          and ammunition.  He also went to Bethesda for back school(approx. week). 
          In summary, the Veteran has been under chronic medical care for neck pain
          first reported during service(6/25/96) and the condition has progressed from
          cervical muscle spasm to mechanical cervical pain syndrome and
          cervical herniated and bulging disc with muscle spasm, cord
          contusion/compression myelomalacia, cervical spondylosis and degenerative
          disc disease, cervico-occipital neuralgia, and cervical radiculopathy with
          bulging disc. A nexus has been established.  Therefore, it is at least as
          likely as not that the claimed condition has direct service connection. 
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