free_spirit_etc

http://www.warms.vba.va.gov/admin21/guide/...iciansguide.doc Chapter 13 - MENTAL DISORDERS 13.1 What general information should be provided in examinations for mental disorders? Information required for a disability evaluation of a psychiatric disorder (or an alleged psychiatric disorder) is essentially no more extensive than a discerning examiner would want for his/her own use in an adequate understanding of a patient. The evaluation requires a report that sets forth a clear and complete word picture of the patient as a whole person, what he/she is like, and how able he/she is to take care of himself/herself and earn a living. The examination worksheets describe the specific requirements for a disability examination for mental disorders. This material supplements them. Specifically, the examination report should include: a. Complaints in a veteran’s own words, recorded between quotation marks. The presenting problems, when symptoms began, their course (chronological evolution). b. Information covering behavior, attitudes, and general health prior to onset of present illness. c. A detailed military history: Where served, combat, when, wounds, decorations, names of units where served. d. A description of the symptoms, subjective and objective, upon which the diagnosis is based. e. An occupational history as it relates to the veteran’s adjustment to his/her work: Pre-service social, employment, and educational history. f. A definitive diagnosis or diagnoses, based on whole history and current examination. (If the diagnosis of a psychosis is made, always qualify by stating “active,” “in full remission”, or “in partial remission.”) Terminology and the basis of the diagnosis must conform to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV); otherwise the report will be returned. The report should explain how the veteran meets the DSM-IV diagnostic criteria for the mental disorder(s) diagnosed. g. An opinion as to mental competency. h. A discussion of social functioning. i. A complete multiaxial assessment should be provided in all cases. 13.2 What constitutes a good longitudinal psychiatric history? a. A detailed history is essential in psychiatric disorders. It should be developed and recorded in full if the examination is an initial one, and in re-examinations it should bridge the period since the preceding examination. b. It is sometimes insufficient to rely entirely upon the history given by the veteran. A study by a social worker should be requested, if necessary. The problem involved, and the period or area requiring clarification, should be clearly indicated c. The examiner should not be tempted into making a spot diagnosis on impressions of the moment. Determining whether a disability is developmental or not cannot be made without a longitudinal study. d. The examiner must have a fair estimate of the personality development, knowledge of all previous illnesses, injuries, residual conditions, other impairments, and a chronological picture of the evolution of the current psychiatric disorder; so that the present condition and disability can be viewed in its proper perspective. 13.3 What indicates the level of social and occupational functioning? a. Of first importance in the consideration of social and occupational functioning is a chronological social and occupational history covering the period since the most recent of any previous reports. b. Taking into account the economic conditions generally prevailing in the veteran’s community, indicators of adequate social and occupational functioning, partial or complete, include the ability to hold employment continuously; the showing of efforts to advance one’s self; satisfactory adjustment to superiors and fellow workers; conformance to social standards of the environment; the absence of eccentricities of behavior or gross errors in judgment; and freedom from the necessity of supervision. c. On the other hand, a history of no real attempt to secure available employment, or a history of frequently interrupted employment plus evidence of defective judgment, abnormalities in behavior, emotional lability, poor community adjustment, or antisocial tendencies, are evidences of poor social and occupational functioning and should be recorded. d. Social integration is one of the best evidences of mental health and reflects the ability to establish (together with the desire to establish) healthy and effective interpersonal relationships. Poor contact with other human beings may be an index of emotional illness. 13.4 What are disability evaluations based on? a. Disability evaluations by raters in the VBA regional offices are based primarily on a combination of the signs and symptoms of the mental health disorder and their effects on social and occupational functioning. b. Raters consider the extent of social impairment, but do not assign an evaluation solely on the basis of social impairment. Impaired social functioning is important for rating purposes primarily as it affects occupational functioning. c. Unemployment because of such extrinsic factors as economic depression, dissatisfaction with work environment, or domestic difficulties is not an indication of occupational impairment. 13.5 What information should be provided to support the diagnosis? A disability evaluation cannot be made merely on the basis of the diagnosis. The diagnosis must be supported by the history and examination findings. For adequate justification for the diagnosis, the examiner should consider the following and record all information of importance concerning them: a. Chronological historical medical, social, occupational, and military data. b. Clearly and fully detailed symptomatology. The examiner will usually need to include in the examination report a statement covering the following main topics: Appearance, attitude, and behavior. Stream of talk and mental activity. Emotional reactions and mood tendencies. Content of special preoccupations. Sensorium and intellectual resources. c. Sufficient data upon which the differential diagnosis can be made. d. Hospital study in cases where indicated. e. The existence of an underlying organic condition that may cause the psychiatric symptoms. f. Resolution of any inconsistencies between findings of specialists. g. Necessity for social work service study. h. Indication for psychological evaluation and results of any psychological tests conducted, to be correlated with other findings. i. Conference with other examiners in the examining unit, if needed. j. A diagnosis must never be made solely by exclusion. In other words the absence of physical findings is not in itself sufficient to justify a psychiatric diagnosis, nor does the mere suspicion on the part of the physician that the symptoms are functional warrant a positive psychiatric diagnosis. 13.6 How should the current diagnosis be related to previous diagnoses? In the interpretation of the veteran’s history and behavior, the examiner should be familiar with previous diagnostic interpretations. One cannot presume that the initial diagnosis, for example in the service medical records, is correct. a. Care is required before changing a diagnosis previously established, especially on more than one occasion, by the same or different psychiatrists. b. Whenever the history and findings of the examination do not confirm a diagnosis that has been previously made, the examiner should record the diagnosis which, in his/her opinion is justified on the basis of all the evidence, but should relate a current diagnosis to a former one, so that the rating boards may clearly understand whether: A current diagnosis corrects an old (erroneous) one. A current diagnosis represents a mere change in nomenclature. Include diagnosis from the old and new Diagnostic Statistical Manuals. A current diagnosis reflects a new phase or later development of a condition formerly diagnosed differently. A current diagnosis represents a new clinical entity not related to an earlier diagnostic entity. c. An examination report which is the basis for a diagnostic conclusion of “No disease, following observation (or careful examination) for psychiatric disorder” should reflect the same careful consideration and thorough examination as required for the diagnosis of a psychiatric disease. d. The examiner is frequently confronted with the absence of any present findings attributable to a disorder previously reported. If he/she is of the opinion that the subsequent course disproves the earlier diagnosis, he/she should so state. If the examiner reaches the conclusion that the formerly diagnosed condition actually existed at some earlier date but that the veteran has recovered, he/she should so state. In either case, reasons for such a conclusion must be recorded. e. A previously recorded diagnosis, if different from the currently accepted terminology, will be parenthesized after the current diagnosis. If the current diagnosis represents an entirely different category of disorder, you will need to provide a summary of the pertinent evidence to support it. 13.7 How should developmental or congenital conditions be reported? Distinction must be made between conditions due to disease or injury and conditions which are of developmental or congenital origin. Primary personality disorders and disorders of intelligence should be fully described and classified. 13.8 How and why should an examiner consider mental incompetency? a. Incompetence for VA purposes is defined in section 3.353(a) of title 38, Code of Federal Regulations, as follows: “A mentally incompetent person is one who because of injury or disease lacks the mental capacity to contract or to manage his or her own affairs, including disbursement of funds without limitation.” This is a determination ultimately to be made by the VBA rater based on all evidence of record. However, the examiner’s assessment regarding incompetency is important and should be reported for two reasons: as a factor in measuring the relative disability. to assist in determining the propriety of payments of monetary awards directly to the veteran or to a guardian appointed by a court. b. While an opinion of incompetency frequently follows a determination that a veteran is psychotic, this is not always true, so a distinction should be recognized between a psychosis as a mental disorder and incompetency as an existing fact. c. A determination of incompetency will be based upon affirmative answers to these questions: Is the individual incapable of administering his/her personal affairs? Is there definite evidence of a more or less prolonged departure from normal behavior as compared with the social standards of the community indicated by such things as dissipation of funds, irresponsibility toward personal and financial obligations, and lack of appreciation of values? 13.9 What pertinent information is available in the claim file and medical folder? The claim file and medical folder may be useful to show: chronological medical, social, and occupational history (including social study, if made). the basis for previous diagnoses. previous ratings. 13.10 What constitutes a good psychiatric examination? a. A review of the physical status, particularly with somatic complaints (including a brief neurological survey) is not only of value to the examiner but reassures the veteran that he/ she has had complete medical attention, even if a physical examination, including neurological examination, is already of record. b. A detailed history as described in paragraph 13.2. c. The examiner does two things at the same time—participates in the interview, and observes general appearance, behavior, and speech production (noting emotional, intellectual, and physiological reactions). The quality of the patient-doctor relationship established and the extent to which the veteran feels accepted and understood will markedly affect his/her feeling toward the final rating decision. d. Knowledge of pertinent data in the claim file and medical record file and skill in interviewing and understanding the objectives are both essential to an examination. e. The following psychiatric interview technique is offered as a suggestion only, since most examiners have their own methods of eliciting information to be used as a basis for diagnostic classification and evaluation: 1) Begin by asking the veteran to relate everything that is troubling him/her. Permit the veteran to give a full spontaneous account of the symptoms and difficulties. Ask no leading questions except in instances where it is apparent that a psychotic process is present. Record verbatim a few representative statements and all complaints. 2) After the veteran has finished an uninterrupted story, inquire what else troubles him/her. 3) Probe each symptom and how long it is present. Note the severity and whether it is persistent or intermittent. Describe its influence or effect upon total functioning, including relationship with others, work, and financial security. 4) Inquire what the veteran has done about his/her symptoms. What factors aggravate and what factors diminish the symptoms? 5) Has the veteran been thoroughly examined previously? What has he/she been told? 6) Inquire what the veteran thinks is behind the symptoms—the cause of them. Did they follow some stress? (Precipitating factors.) 7) Determine how the veteran felt about him/herself before the onset of the present trouble. 8) While the veteran is relating the story, formulate your impression concerning the following points: (a) How much discomfort or trouble does the veteran seem to be having as a result of the symptoms? (:) Is the emotional display consistent with the symptoms? © Does the veteran seem to be exaggerating? (d) Is the veteran apprehensive or anxious? (Note objective signs of anxiety.) (e) Consider the question of emotional immaturity, a pathological personality, or a disorder of intelligence. (Request psychological consultation if certain tests may be expected to contribute to an understanding of the disorder). (f) The extent of impairment of insight and judgment. f. The eliciting of information through the interview, plus an interpretation of the material contained in the claim file and medical record file, an evaluation of a social study (if one has been made), and an assessment of special tests, should furnish the examiner with sufficient facts to provide a comprehensive report. 13.11 What is the value of and best way to use the Social Work Service? a. A study by the social work service examines significant experiences related to family interrelationships, education, psychosexual development, employment, military history, and the onset of medical or psychiatric problems. They are examined in terms of their effect on the veteran’s psychosocial development and functioning. b. The social study will assist the examiner in developing an appropriate diagnosis; in evaluating the degree of social, psychological, and industrial impairment; and in assessing the veteran’s potential for improved social functioning and employment. c. A social study can help to clarify: The nature and sequence of events that may have affected the veteran’s life. The physical and social situation, and especially the interpersonal relationships, past and present, that have perceptibly affected him/her. Social and psychological situations that may have brought out abnormal functioning which has a bearing on the cause and nature of the veteran’s maladjustment. Information about the veteran’s behavior patterns. Response to stressful situations. Competency . d. Social data are particularly useful in helping the examiner solve diagnostic problems such as differentiating between a transient personality reaction to an acute or special stress and an anxiety or other type psychiatric disorder; determining the significance of addiction to alcohol or drugs; indicating the existence of delusional trends, and determining what continuity of symptoms has existed over periods during which there have been conflicting diagnoses. e. A social study may focus on the psychogenic factors in an illness where the obvious symptoms may be the disordered function of an organ or system of the body. f. Finally, the social study may provide additional information concerning the veteran’s readiness for treatment and potential for response to treatment. 13.12 How can psychological tests help? The use of some of the many objective and projective psychological tests can aid the examiner materially in making a complete diagnostic evaluation. Although the test findings are not a substitute for a psychiatric examination, they can provide many corroborative facts through investigating the presence, extent, and severity of symptoms. Further insight into sources of anxiety and unconscious conflicts as well as descriptions of characteristic defense reactions to stress and frustration can be secured. Additional facts concerning the veteran’s motivation, goals, aspirations, needs, and attitudes can also be obtained. a. Psychological tests can aid in the differential diagnosis of psychiatric and neurological disorders and reactions psychoses and anxiety and personality disorders psychotic and anxiety disorders mental retardation and schizophrenia mental retardation and organic brain disease. b. Various tests can be used to delineate some of the veteran’s outstanding personality traits and modes of expressions, such as: emotional responsiveness and control the degree and quality of ideational activity the degree to which he/she functions within the limits of capacity without undue inner tension or stress. c. Tests can determine the differential effects of organic brain damage and psychiatric illness upon the psychological functions, such as memory, perception, and reasoning, as well as the degree of impairment. d. Facts concerning the potential and resources of the veteran which are useful in judging the likelihood of improvement or recovery can also be provided. 13.13 Consultations An examination by an appropriate consultant may be required in cases where there is the possibility of an organic condition being either a cause or a result of a psychiatric disorder. Worksheet - EATING DISORDERS (Mental Disorders) Name: SSN: Date of Exam: C-number: Place of Exam A. Review of Medical Records: B. Medical History (Subjective Complaints): Comment on: 1. Past Medical History: a. Previous hospitalizations and outpatient care for parenteral nutrition or tube feeding. b. Medical and occupational history from the time between the last such rating examination and the present needs to be accounted for, UNLESS the purpose of this examination is to ESTABLISH service connection, then a complete medical history since discharge from military service is required. c. Periods of incapacitation (during which bedrest and treatment by a physician are required due to the eating disorder). Describe the frequency and duration. d. Current treatment, response, side effects. 2. Present Medical, Occupational and Social History - over the past one year. a. History of onset of eating disorder. b. Its course, treatment, and current status to include symptoms. c. Extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job. 3. Subjective Complaints: a. Describe fully. C. Examination (Objective Findings): Address each of the following and fully describe: 1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV. 2. Additionally, please provide this specific information: a. Current weight. b. Expected minimum weight based on age, height, and body build. c. Obtain weight history. 3. Additionally, to allow evaluation by the rating specialist, describe and fully explain the existence, frequency, and extent of the following signs and symptoms and relate how they interfere with employment: a. Binge eating. b. Self-induced vomiting or other measure to prevent weight gain when weight is already below expected minimum normal weight. D. Diagnostic Tests (including psychological testing if deemed necessary): 1. Provide specific evaluation information required by the rating board or on a BVA Remand. Diagnostic Tests (See the examination request remarks for specifics.): a. Competency: State whether the veteran is capable of managing his or her benefit payments in the individual's own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs). b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA Remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing please state WHY. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "...is it at least as likely as not...", fully explain the clinical findings and rationale for the opinion. 2. Include results of all diagnostic and clinical tests conducted in the examination report. E. Diagnosis: Signature: Date: Worksheet - MENTAL DISORDERS (except PTSD and Eating Disorders) Name: SSN: Date of Exam: C-number: Place of Exam: A: Review of Medical Records: B. Medical History (Subjective Complaints): Comment on: 1. Past Medical History: a. Previous hospitalizations and outpatient care. b. Medical and occupational history from the time between last rating examination and the present, UNLESS the purpose of this examination is to ESTABLISH service connection, then the complete medical history since discharge from military service is required. 2. Present Medical, Occupational, and Social History - over the past one year. a. Frequency, severity and duration of psychiatric symptoms. b. Length of remissions, to include capacity for adjustment during periods of remissions. c. Extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job. If unemployed, note in Complaints whether veteran contends it is due to the effects of a mental disorder. Further indicate following DIAGNOSIS what factors, and objective findings support or rebut that contention. d. Treatments including statement on effectiveness and side effects experienced. 3. Subjective Complaints: a. Describe fully. C. Examination (Objective Findings): Address each of the following and fully describe: 1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV. 2. Additionally, to allow evaluation by the rating specialist, describe and fully explain the existence, frequency, and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning: a. Impairment of thought process or communication. b. Delusions, hallucinations and their persistence. c. Inappropriate behavior cited with examples. d. Suicidal or homicidal thoughts, ideations or plans or intent. e. Ability to maintain minimal personal hygiene and other basic activities of daily living. f. Orientation to person, place and time. g. Memory loss or impairment (both short and/or long term). h. Obsessive or ritualistic behavior which interferes with routine activities (describe with examples). i. Rate and flow of speech and note irrelevant, illogical, or obscure speech patterns and whether constant or intermittent. j. Panic attacks noting the severity, duration, frequency and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation. k. Depression, depressed mood or anxiety. l. Impaired impulse control and its effect on motivation or mood. m. Sleep impairment and describe extent it interferes with daytime activities. n. Other symptoms and the extent to which they interfere with activities. D. Diagnostic Tests: 1. Provide psychological testing if deemed necessary. 2. If testing is requested, the results must be reported and considered in arriving at the diagnosis. 3. Provide any specific evaluation information required by the rating board or on BVA Remand (in claims folder). a. CAPACITY TO MANAGE FINANCIAL AFFAIRS Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest. In order to assist raters in making a legal determination as to competency, please address the following: What is the impact of injury or disease on the veteran's ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently? Does the veteran handle the money and pay the bills himself or herself? Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion. If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran's ability to manage his or her financial affairs, please explain why. b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA Remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing, please indicate why. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "...is it at least as likely as not...?", fully explain the clinical findings and rationale for the opinion. 4. Include results of all diagnostic and clinical tests conducted in the examination report. E. Diagnosis: Provide: 1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report. 2. If the diagnosis is changed, explain fully whether the new diagnosis represents a progression of the prior diagnosis or development of a new and separate condition. 3. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship. 4. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning. NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying compensation for a disability that is a result of the veteran’s own ALCOHOL OR DRUG ABUSE. However, when a veteran’s alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran’s alcohol or drug abuse. F. Global Assessment of Functioning (GAF): NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.) Signature: Date:

Yep! It is definately a start. You can always get more later. And a doctor would be more willing to support an opinion he had already given. We scared off a doctor by asking for too much too soon. It is the pulmonologist who first told my husband his cancer began in the service. We asked for a letter and he informed us that he would write it. And then when I told him the way it would have to be written, he balked. He called back and said the base attorney said they are not "allowed" to issue opinions. (He was a base doctor). It is probably better to get them to write ANYTHING. And then suck the rest out of them later. The oncologist USED to work on base. He was also unwilling to write a letter. At first he said he couldn't because they are not "allowed" to state opinions - JUST FACTS. My husband finally wrote a letter that told the doubling rate of his type of cancer. He signed that without balking much - but it wasn't enough. It can be used to SUPPORT other evidence. We have bits and pieces from several places - but they won't connect the dots. All we need is someone to say "The average doubling time of this type of cancer is 180 days. His tumor was 3.1 cm when detected 2 years post retirement. Based on the average doubling time, it would take a tumor of that time 12 - 15 years to reach 3.1 cm. It is more likely than not that his cancer did not grow to the size in 2 years that normally takes 12 - 15 years to develop). We have it all. Just not someone that says it ALL in ONE place. The oncologist says it doesn't matter what he writes because they will use their own doctors and make their own decisions. Every snowflake in an avalanche pleads not guilty. ~ Unknown

So the difference is - they took off the part where it says you were examined - and left the opinion. This might seem like a SMALL thing to some people, and I'm sure the VA will try to say it was an innocent error, which was corrected. However, I think it is important BECAUSE: 1. You do NOT "correct" a medical record by deleting something. You correct it by stating the correction. They could have simply stated - The previous entry is in error. This was not an examination. It was merely a follow up report by ___" To DELETE something usually indicates you are trying to cover something up...make an error go away. That is not to say they INTENDED to cover it up. They may have merely been trying to correct it. Sometimes they don't have a clue. But they need to GET a clue - if they are working with medical records. 2. They told you it affected your case. And then the evidence that it was ever THERE disappeared. Again, they may NOT have done this with the INTENT to harm. But again, that is why rules are in place. If you had not SAVED a copy of the OLD report - you would have been told that thinking it was an exam affected your case - you would have started complaining about how it said you had and exam when you didn't - and ALL the EVIDENCE would been GONE - and the BVA would have thought you were just being a NUT. No matter how much you complained - you wouldn't have been able to PROVE it - as they had destroyed the evidence. Again, I wouldn't so much say they deleted it in order to destroy the evidence. But reguardless of their intent, it had the same outcome. Luckily, you have a copy of the OLD one. 3. This calling opinions exams is NOT unique to your case. It happens to MANY vets The VA is aware of the fact that if something is called an exam - people will think it was one. The VA is constantly seeking both exams and opinions - and though they have a zillion forms - it has not seemed to occur to them to create a different form for a doctor to report an opinion than to report an exam. To say EXAM indicates you were EXAMINED. To use the term is totally misleading if it is a medical opinion. I bet if you turned something in to THEM that SAID EXAM, when you had NOT been examined - they would throw it right out. They need to get their stuff straight and stop calling reports and opinions exams - as it is most likely affecting many veterans. Here is an EXCERPT from the letter we sent them about my husband's NON-exam they called an exam: I consider the examination report of March 2002, by Mxxxx, at XXX VA Center, (Attachment 7-1c in my evidence packet) regarding my lung cancer to be totally inadequate for the following reasons and request that it not be used as a basis in determining my case. According to the C&P Service Clinician’s Guide § 4.2 “1.11 If an examination report does not contain sufficient details to adequately support the diagnoses (unless the diagnosis is already well established) or sufficient information about the current findings and effects on functioning, the RVSR will return the report as inadequate for rating purposes. (38 CFR 4.2) 1. The examiner did not examine me. Though the report is labeled as an examination, the examiner never met with me. The examiner indicated in his report that he was requested to offer an opinion after review of the medical records whether there is a relationship between my currently detected lung cancer and exposure to asbestos in the service, or to give an opinion as to any other etiology. There is nothing in the examiner’s report which indicates he even talked to me, let alone examined me. The VA examiner issued his report / opinion after a review of some of my records. However, issuing such a report as a “Respiratory Diseases, Miscellaneous Exam” is misleading, and could be mistaken for an actual examination under the VA Clinical Guidelines, which it is not. 2. The fact the examiner stated I had no shortness of breath, and did not have any apparent residuals of the lung cancer I was treated for without even examining me raises a legitimate question as to the credibility of his report. My pulmonary function tests done at the same VA facility on March 19, 2002 (the same day the VA examiner indicated he reviewed my medical records – and five days before he signed the report) noted that I had dyspnea on hills and stairs, frequent wheezing, and decreased FVC (73% predicted) and decreased FEV1 (69% predicted) According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.). FEV-1 of 56- to 70-percent predicted should be rated at 30% The examiner did not even mention my pulmonary function tests done that day, yet he declared I did not have any apparent residuals of the lung cancer. Though it is part of my medical record, it is not clear whether the examiner realized that I had a left lung lower lobectomy before he issued his opinion on my residuals, as he failed to mention it in the report. My DLCO was 51% on my pulmonary tests at xxxx in xxx. These were also part of my medical record. According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.).DLCO (SB) of 40- to 55-percent predicted should be rated at 60%. I am not saying for certain that my residuals should have necessarily been rated as a 30% or 60% disability, but I am saying that the decreased levels on the PFTs, which were CLEARLY of record, indicate that that a determination should NOT have been made that I did not appear to have ANY residuals without so much as mentioning the PFT levels, let alone articulating medical reasoning to support such a conclusion. This is especially important in light of the fact the examiner did not even provide me with a physical examination prior to issuing his opinion on the lack of residuals from my cancer. The C&P Service Clinician’s Guide 6.1 d) 4. states “If the DLCO test is not included as part of pulmonary function testing, the examiner should determine whether or not it would provide useful information about the severity of pulmonary functioning in a particular case. If it was not done as part of the routine testing, and would not be useful, the examiner should explain why, e.g., by explaining that the DLCO would not be valid in this particular case because of the decreased lung volumes. Unless an explanation for its omission is provided, the DLCO should be done.” Though my DLCO’s of record were low, no DLCO was done as part of my pulmonary functioning testing. Nor was there any explanation as to why a DLCO was not done prior to his determination that I had no residuals from lung cancer. Again, I question the adequacy of his report. As I also have resected ribs, an 11 inch long depressed scar spanning from my scapula to under my arm, etc. I question the ethical soundness of a physician making a determination that I had no residuals of lung cancer merely from reviewing some of my medical records, without so much as seeing me, and without articulating sound medical reasons for doing so. Yep. They need to STOP calling NON-exams Exams. I couldn't get over my husband's SOC going on and on about "You TOLD the doctor this and you TOLD the doctor THAT - because they THOUGHT he had SEEN the doctor. Free

Another thing to WATCH on the form - the ORDER of their statements are MISLEADING! In my medical opinion, the currently existing medical condition is Related to Possibly related to More likely than not related to and injury, illness, or event occuring during the veteran's military service. The way they PLACED "possibly related to" would give people the tendency to check THAT Box if it wasn't a certainty - but was MORE than 50%. However POSSIBLY related to does not give any point of reference. Possibly can be ANYWHERE between 1% and 99%. Note - a good portion of possibility is UNDER 50% Free

Thanks for the form. I wonder why they have it so simple though - Just having them check the box and put in your diagnosis, when they know dang good and well - if the doctor doesn't state HOW it is related, and WHY it is related, they aren't going to pay attention to what box he / she checked. But at least it's a start :) Free

I'm not Berta - but I am throwing in my two cents... First and foremost, I am so sorry to hear about your friend. And how great of friend you are to be there right now for him - and to help make sure his wife is taken care of. First - if they have ANY evidence that needs to get to the VA on ANY claim - get it there -- for the accrued benefit claim - anything that might be due to him(so it was IN his file). You might want to send in SOMETHING - even an IRIS - to CLAIM the cancer - and will still have time to pull it all together formally later (as another doctor might be able to link the cancer to AO / the service even if it isn't on the presumptive list). I'm not sure about benefits continuing - there might be a gap - but she might be able to get them again. Not sure about Pension - that is also a possibility. Also Social Security.. My thoughts and prayers are with you..your friend..and his family.. Free

http://books.google.com/books?id=SkeBPgOJm...I8Eqjg#PPA73,M1 Long link - but I copied and pasted it and it worked.... I like what it says about tampering with medical records... especially the part where the judge can instruct a jury that if there are any deletions in a medical record - the jury can PRESUME that the person was negligent, even with NO other evidence, because any deletion gives the presumption of wrongdoing and an attempt to cover it or hide it. Free

Josephine, Yeah..they can't just take their mistakes out. They should have issued a NEW ammendment - Not REPLACNG the first one - but explaining it, such as C&P exam of __ never occured. Is it possible the Nov. 16 C&P exam they referred to is the OPINION the doc wrote? That is what I was thinking. My husband kept telling me he never GOT a C&P for his cancer. I thought he forgot or something - because the SOC kept saying "You told the doctor this, you told the doctor that..blahblahblah.." When I got a copy of his report - it was ON a C&P form - and it stated date of exam - and they had a date, which was actually the date he reviewed the medical records --there WAS no exam. He clearly said in his OPINION (that was written up AS a C&P) that he was asked to provide an opinion as to the etiology of my husbands cancer AFTER a view of the medical records. He did NOT examine my husband. My husband DID get some tests that day - but the doctor didn't even report those. For instance, the resp tests (done THAT day) showed that my husband had decreased PFTs and wheezing and shortness of breath on hills and stairs -- but the doctor reported he had NO problems - NO shortness of breath - NO apparent residuals from the lung cancer. WITHOUT so much as SEEING him. He was missing half of a lung - had a HUGE scar - increased DLCOs, decreased PFTS, shortness of breath - and WITHOUT so much as SEEING him the doc wrote that he had NO lasting effects from the lung cancer. (The cancer he ended up dying from). I wrote to the VA - and pointed this out. It is NOT a C&P - but if you LABEL it a C&P and REFER to it as a C&P - then raters think it WAS a C&P. They are fully allowed to seek medical opinions without exams. But they need to dang well lable them as such - and quit calling them something they are not. Yes..it could make a difference if a rater thought the doctor who wrote the opinion had SEEN you AGAIN. Of course, they can SAY it wouldn't have mattered - but - let's use their terms - it is more likely than not that it would. So TWO issues: 1. They have no right to delete ANYTHING from the records. If they found out you didn't have a C&P (which THEY should have known in the first place) then they should have NOTED that in the record (Nov 16 C&P was reported in error. No C&P occured at that time) or something like that - instead of just taking it out. 2. You were told that the results might have been different had the known you didn't have a NEW C&P. I wish you could attack the heck out of this because they need to find a way to ask doctors for their opinions WITHOUT making them look like C&Ps - and so the raters will at least know what in the heck it was...especially since they seem to give more credibility to reports made when a doctor SEES you. I think my FIRST step might be though - to not let them know that you are ON to that...but get a paper trail STARTED. Send in a IRIS - something like: I know my record was reporting that I had a C&P on Nov 16. This was incorrect, as I did not have one. ___ informed me that this mistake affected my claim by --- (whatever it did). I would like to know if the mistake has been corrected and so it will not continue to have a negative prejudicial effect on my claim. The reason I would do that is to get SOMEWHERE IN WRITING that you were TOLD that the mistake had a negative effect on your claim. But I would keep it kind of general - so they won't balk at it. Because I think they will later DENY this had ANY negative impact on your claim. So I was thinking of writing something that seems semi-innocent (I'm sure you are good at that <_< ) and get it in writing and see if you get a response - mostly just to get something in writing SOON that it had a negative impact. Then go at getting them for altering your medical records. BEFORE you write the IRIS - wait and see what some of the experts say though - I may be off base here. FREE

My husband filed for SC for lung cancer prior to his death Feb. 5, 2007 I filed for DIC and accrued benefits May 2007 I have just been WAY busy and haven't been following up aggressively on the claim - but get a bit of time to work on it from time to time - and it is getting close to moving toward the top of my priority list as soon as I get done wading through everything else that is above it. I have some questions I can start working on a bit now. 1. I received a denial and SOC on November 8, 2007. This was prior to the one year I had to submit evidence. I know I will have to get an IMO to submit. When I get the IMO should I a. Submit it and any other evidence I have and ask that make a decision on my claim as I submitted the evidence within the one year time frame (and they made a decision before that)? b. Just go ahead and accept that their initial denial is a denial - and submit a NOD with my evidence - which would put me a step closer to the appeal I might have to go through. c. Both - ask them to make a decision based on the new evidence submitted in one year AND file a NOD - d. Same as c - but WAIT on the NOD (I have until November 2008). Medical Opinion Though they actually ACKNOWLEDGED that my husband was requesting consideration on the theory that his cancer must have begun in the service - the reasons they gave did not have anything to do with that theory.(Based on the growth rate - the cancer could NOT have STARTED after retirement). They specifically said: "To assist in gathering evidence to support the claim, we requested a VA medical opinion. In response to that request, a VA physician reviewed the records and noted that the symptoms noted during the veteran’s treatment in the service suggest manifestations of viral respiratory tract illness, and that none of the episodes can be reasonably linked to an early manifestation of lung cancer. He then provided the medical opinion that the veteran’s signs and symptoms listed in his service medical records are less likely than not early manifestations of the adenocarcinoma of the lung first diagnosed in September 2000. So they blew off the whole growth rate argument - and just addresed whether any SYMPTOMS in the service were related to the cancer. I have researched cancer and growth rate at the BVA and come up with TWO distinct patterns. Those which GRANT service connection because of more likely than not IMOs based on growth rates. Those who ARGUE growth rates - but do NOT provide an IMO - which then leads the VA to somehow FIND a medical specialist who says something about how the medical community accepts that the ONSET of cancer is when it is DIAGNOSED. This is completely idiotic - as the medical community knows fully well that cancer STARTS BEFORE it is diagnosed - which is why they keep pushing for earlier and earlier SCREENINGS. But - it is a BIG lesson on EVIDENCE. No matter what the journals SAY - you need a DOCTOR to SAY that the cancer started before it was diagnosed to get the GRANTED type of decision - because if you leave it to THEM - they will find the doctors who say that cancer starts at diagnosis - and you will get a DENIED type of decision. Anyway - I am asking for a copy of the VA doctor's opinion. I am also asking for a copy of the request they sent for that opinion. (Because if they only ASKED him to discuss if the symptomology in service was related to the cancer - they prejudiced the claim by limiting what he discussed. I am not going to ARGUE that right away - because if his report isn't favorable - then I don't want to give them a reason to let him discuss any more - However, I will keep it as a back up. Anyway - Since we already asked they consider the theory of that the cancer had to have started in the service - and they specifically acknowledged that was the request - and they have ALREADY had their opportunity to GET a medical opinion about that - then if this doctor played around and just discussed the symptoms in service - have they already USED their chip to get an independent medical opinion? What I am asking - is now that they played their hand in whatever way they played it - if I get a medical opinion that indicates it is more likely than not that the cancer started in the service (regardless of whether there were any symptoms) - can they seek ANOTHER opinion that addresses THAT? Or would that be a "fishing expedition? The growth rate argument is not unique. The BVA has granted many cases based on that same theory. In fact when I typed in a search at the BVA with Cancer and Doubling Time - I saw GRANTED GRANTED GRANTED. SO they know EXACTLY what we are talking about - they just have danced around the issue. Also - my understanding was that the VA doctor was supposed to view the ENTIRE C-file. As my husband has repeatedly stated his cancer began in service - has repeatedly stated his doctors told him that based on growth rates, and the LAST evidence we submitted was all the treatisies that expounded on that - If the doctor didn't even address that - and only discussed symptoms in service - then again, will they be "allowed" to seek ANOTHER opinion after I submit an IMO. I guess I am looking for a way to prevent that game. Some GOOD news is that they actually CALLED the evidence we submitted " a bound volume of medical treatises" and NOT "internet printouts." I consider that a GOOD sign - and the information we sent is from sources such as the National Cancer Institute, Center for Disease Control, FDA, peer-reviewed journals (NOT anything they could question the credibility of).

This is a pretty interesting historial document on Agent Orange. Interesting on how the VA and other governmental agencies stacked the decks on the early studies. Also has some interesting discussion on the VA requiring distinct causal relationships - when the benefit of the doubt doctrine just requires statistical significance.(more likely than not) http://www.gulfwarvets.com/ao.html

I am concerned about sending things by certified mail - as you have proof that you sent SOMETHING, but no proof of what you actually submitted. (i.e. they can lose PARTS of what you sent and claim they never received them). I am dealing with the RO in Chicago. However, there is also a Regional Office in St. Louis that is only 15 minutes away from me. Can I take documents to St. Louis and get them file-stamped and sent to Chicago from there? Free

A Statement of Case I received refers to a Medical Opinion. I sent an IRIS to ask for a copy of the opinion. They told me to send a written request and tell them what opinion I am referring to, since my husband's record is so "large." My questions are: 1. I REVIEWED his case file last July and didn't see any such medical opinion. Is it possible they have the date wrong? And they didn't request the opinion until October 2007 - instead of 2006? If so - should I mention that? (i.e. I don't want to spend forever waiting for this opinion only to receive a letter telling me their is NO opinion dated Oct. 19, 2006) Or since I AM asking for the opinion they referred to in the SOC - will they most likely send it, even if the DATE is wrong? 2. I asked for his ENTIRE C-file LAST JUNE. My husband requested his file in August 2006. But they didn't provide it by the time he died in Feb. 2007. I had to RE-REQUEST it after he died. I sent a written request on June 14 of 2007 asking to: a. recieve an copy of his entire C-file b. be allowed to VIEW his C-file c. expedite a limited request for a copy of his discharge physcial while I was waiting for the entire folder. This was on ONE request. They let me view the C-file July 2007. But have not provided me with a copy. They usually say it takes 6 months or more to get a copy. They never did find a copy of the discharge physcial (though one of the VA doctors referred to it in his opinion. However, I have NOT recieved the letters my husband used to get telling me they are working on it. So I am beginning to wonder if they figured since they let me SEE the file, they don't have to follow up with giving me COPIES of the file I requested. I am considering adding to THIS request that this request does not REPLACE the request for the ENTIRE C-file I submitted last June. But I am concerned that if I even MENTION getting the whole C-file NOW - they might stick this request in the "we will get to it in 6 months pile" - and I would like to get this SOONER than that. So is it okay to send in this LIMITED request NOW - and then follow up after I get this medical report with a reminder that the June 14, 2007 request for the ENTIRE C-file has not been fulfilled? This is a copy of what I am sending: Privacy Act Request for Access Letter January 20, 2008 Re: Privacy Act Request for Access / FOIA request Re: xxxx CSS xxxx To Whom It May Concern: This is a request under the Privacy Act of 1974. Please consider that this request is also made under the Freedom of Information Act. This is a limited request for records under the Act. The Statement of Case I received from the VA dated November 8, 2007 states that part of the evidence considered was a Medical Opinion dated October 19, 2006. The Reasons for Decision section states: “To assist in gathering evidence to support the claim, we requested a VA medical opinion. In response to that request, a VA physician reviewed the records and noted that the symptoms noted during the veteran’s treatment in the service suggest manifestations of viral respiratory tract illness, and that none of the episodes can be reasonably linked to an early manifestation of lung cancer. “ In order to assist in the development of my claim I would like to receive: 1. A copy of the Medical Opinion dated October 19, 2006 2. A copy of the request for a medical opinion the VA sent to the VA physician. 3. Copies of any other documents related to the VA’s request for a medical opinion and the VA physician’s response to that request. Thank you, xxxxx

Congrats! It looks like he knew their game, and called them on it. Both the game of giving nonsubstantiated diagnosis for early discharge, and the game they have been playing with your claim. Free

I was thinking that the C&P docs (the second two) ALSO gave you a diagnosis of Anxiety on Axis one..and that they stated that the majority of your symptoms were related to your personality disorder (thus causing your disability). However, I don't recall that they gave any medical rationale for discerning which symptoms were caused by the Anxiety and which were caused by the so called personality disorder. It is my understanding that if they can't seperate out which symptom is caused by what - they have to give the benefit of the doubt to the service connected condition. I know you haven't got service connection yet - but still. No problems before service. Anxiety Problems and treatment in service. Treatment for Anxiety over many years. So called Personality Disorder diagnosed after no type of testing that is under the standard of care for the field - many YEARS after the service. All of a sudden - they want to attribute your symptoms to personality disorder - and say it predates service. Again - it is not a bad thing that they are putting it WAY back there, because you have good lay evidence you had no noticible problems pre-service. But if your so-called personality disorder is so disabling, why did it take so many years to diagnose it though you were under constant medical care? And why was it diagnosed ONLY by two C&P docs who didn't do the appropriate tests? And again, wasn't it a PSYCHOLOGIST who gave you your first C&P. Why are they disregarding that? Psychologists are MORE qualified to do psychological testing and diagnosing than PSYCHIATRISTS. In fact, psychiatrists SEND their patients to psychologists to have the psychologistdo the testing and interpreting of tests. Psychiatrists do very little training on testing and interpretations of tests in their medical training - because that is the realm of psychologists. Just like you medical doctor sends you to radiologists, physical therapists, etc... to people who are TRAINED to do that specific thing, - psychiatrists send patients to psychologists to do the testing and intepretation of tests. Anyway - even THEY gave you an anxiety diagnosis. But they gave NO medical rationale as to why they have determined in ONE visit that your ongoing problems are related to your so called BPD, rather than the anxiety that even they diagnosed. Free

In our professional opinion, the propenderance of the evidence, including the letters by Dr. Cxxxxx and Pxxxx, supports the initial findings and diagnosis of the examiners and suggest that the etiology of her anxiety appears to have preceded her time in service. Yep. You have a strong argument for that. That the evidence has clearly shown that you suffered from anxiety in the service. That the only disagreement has been the etiology of the anxiety. That the only disagreement about the etiology was, in fact, done by the doctor performing the second C&P. That the diagnosis was made ___ years post service and was also made without adequate testing and without following medically established standards for care for diagnosing personality disorders. That the doctor who gave that diagnosis failed to provide any medical bases for maintaining such and opinion – and failed to reconcile their opinion in light of the additional evidence as directed by the BVA. That an opinion based on the “preponderance of the evidence” which says the etiology of the anxiety “appears” to have preceded your time in service does not come near the “clear and convincing” evidence standard required to rebut the presumption of soundness, especially in light of the other testimony which shows no indication of anxiety prior to the service. Free

Berta, Thanks. My husband wasn't treated by the VA - he only went there for C&Ps -- but he was treated by the physicians at the Base (retired - TriCare) and by the doctors they referred him to). We have most the medical records (private and AF Base) and most of the SMR's. I am still missing the discharge physical that we have been requesting - and I tried to see last year when I drove to Chicago. Previous C&Ps remarked about my husband's discharge physical. However, there was no discharge physcial in his file when I viewed the records last summer. I followed up with a written request asking them to locate it and send me a copy. They responded by telling me that the file was complete - and that if there wasn't one in the file they couldn't provide me with one. I have no idea where they could have put it and they aren't willing to look for it. They did send me a VCAA letter - but they only addressed the asbestos exposure part of the claim (as has been their pattern.) Over and over my husband would write them and say -You have NOT acknowledged or addressed the fact that I am reporting my cancer STARTED in service. They would respond with - You need to send us proof of asbestos exposure. It is like they know full well that his cancer started in service so if they can pretend to not notice that portion of the claim - they won't have to pay. At least this time they acknowledged that he alledged the cance started in service - though the only thing in the denial letter that addressed it (somewhat) was that the doctor had said the symptoms he had in service were not related to the cancer. We never said that they were. They totally ignored the whole argument of growth rates of cancer and focused on symptoms alone for a disease which is known to be asymptomatic. They also did send me the election form. I did not sign it and send it back in yet - as I was going to wait until I had finished sending evidence. I did write and request a copy of his c-file and specifically his discharge physical and so I could finish submitting his claim - but I haven't recieved them. Free

Thanks for the info. I will MAKE ANOTHER request for the whole C-file - and an expedited request of the doctor's report. They don't get in ANY hurry in Chicago and will rountinely tell you that it takes at least 6 months to get anything. What gets me is you have to file appeals in a certain time frame - but don't have access to the information with which to appeal. Maybe I can write to my congressman and ask for them to help me get copies from my file. My husband requested copies in I think it was August 2006 and didn't recieve them before he died in February. I requested them again last spring - and still haven't received a copy. Free

Thanks Pete! Free

Good point. The VA is a somewhat "closed" system, answerable only to itself. However, the doctors also have to hold a license and be regulated by professional boards. You kind of wonder what professional licensing boards might think of someone tagging you with a diagnosis without doing appropriate testing in order to deny you benefits.

The current request involves consideration of letters by Dr. B. Cxxxxxx and Dr. Pxxxx and " to reconcile their opinion as to etiology". In our professional opinion, the propenderance of the evidence, including the letters by Dr. Cxxxxx and Pxxxx, supports the initial findings and diagnosis of the examiners and suggest that the etiology of her anxiety appears to have preceded her time in service. So they didn't drop the personality disorder diagnosis - they just didn't mention it by name. However, I think this slight back paddling should help you a bit. The first time they asked them they merely said they hadn't changed their mind. If that answer was adequate --the AMC should have stopped then. However, they must have found the "we haven't changed our mind" type opinion to be inadequate --because they asked them AGAIN. After all - the BVA said they needed to RECONICLE their opinion - so the AMC gave them another chance to reconcile it (i.e. make it fit with the other evidence. Their new opinion is just a fluffier way of saying "we haven't changed our mind." They gave no medical rationale for why their opinion remains the same. Geez -- they should have been AT LEAST able to pull SOMETHING out of those reports to say "so and so reported such and such --which is consistent with balh blah blah.." But they didn't do that. They just fluffed up their first answer and said - in essence - Yep we read everything and it supports what we thought and we haven't changed our mind... I don't call that reconciling my opinion in light of the additional evidence. And apparently the VA didn't either - unless they want to pretend the new fluffed up version is "real" because it looks a bit fluffier. And I think it is good that the quacks backpaddled a bit -- their opinion wasn't that strongly stated. They tried to toss out something that might please someone who would want to deny you - but they didn't back it strongly. It isn't adequate for what the VA requested -- but I don't know how much I would point that out. WOuldn't want them to decide to take the second option of sending you to another C&P. I think if the AMC doesn't grant your claim - you could do well with the BVA as the "reconcilation" weakened the quack C&P because they weren't willing to stand behind it with any medical rationale. And it should be getting to the point where they have to DECIDE -- they can't keep sending you back to C&Ps forever until they finally find someone who is willing to write you a crappy C&P after doing adequate testing and is willing to give rationale to back their opinion. One thing I find amazing is that for anything else -- a diagnosis 30 to 40 years later is next to impossible to connect to service. However, YEARS down the road with no personality disorder diagnosis in between - they can just have a couple of doctors spend a bit of time with you - and profess to know what you were suffering from 40 years before. Amazing. Where is THEIR Nexus??? Free

There are a few companies offering these. I would think that IF the evidence would be IN your favor (as more likely than not) -- especially if the evidence is strongly in your favor -- that evidence based medicine could very well support a claim - because it is based on medical rationale -- i.e. evidence. Like in my husband's case -- a doctor could SAY that his cancer might have started after the service - but medical evidence of cancer would probably show that would be very unlikely. They actually also have doctors who will testify. It looks like lawyers are starting to use these reports -- Anyway - it looked interesting -IF the evidence would be strongly in your favor. http://www.nmrco.com/evidence.asp What are the types of Evidence-Based Reports? There are several types of Evidence-Based Reports. Peer File Reviews (PFR) Following review of medical records and other information, an NMR specialist will provide a report based on the evidence from the history, physical findings and testing as well as on literature from the scientific community. The PFR will provide answers to questions such as validity of diagnosis, medical necessity of investigations and treatment, need for surgery, impairments or disability. Evidence-Based Independent Medical Examinations (EBIME) NMR provides IMEs throughout North America by Practicing Board Certified Physicians of all specialties. NMR’s specialists offer expert evaluations of a full spectrum of medical conditions such as cardiovascular, endocrine, pulmonary, orthopedic, neurologic and psychiatric diagnoses. NMR’s IME services: Determine appropriate type of specialist needed Select specialist in vicinity of examinee Schedule appointments Communicate with client, examinee and specialist Provide directions to physician’s office Resolve problems - reschedule, etc. Provide quality assurance of reports NMR’s Quality Assurance program will ensure that the IME report will: Be clear, understandable and defensible Answer your questions IMEs are used by the insurance, managed care and legal industries to determine: Validity of diagnoses Causation of medical conditions Medical necessity of: - Testing - Treatment - Hospitalization - Surgery Maximum medical improvement Restrictions and limitations Impairment or disability Reasonableness of coding and fees Answers to other health-related issues Evidence-Based Medical Report Evidence-based evaluation by a Board Certified Specialist with medical literature references to support the validity of diagnoses, severity of diagnoses, impairments, limitations and restrictions, and retained functional abilities. The claimant may have multiple diagnoses or conditions to be evaluated. The medical decision-making may be complex and the report provides a thorough explanation of the evidence that indicates the claimant's level of function. For Worker's Compensation cases, the report also includes a review and evaluation of medical care/treatment. Comprehensive Peer Assessment (CPA) Evidence-based assessment by a Board Certified Specialist, who will perform a thorough evaluation of the claimant's information. The Specialist will determine if there is adequate information in the medical records to accept or reject the opinion of the treating physician who has endorsed disability. If there is insufficient information, the Specialist will perform a teleconference and indicate to the treating physician any additional testing, specialty consultations, FCE, etc., which are needed to support work loss. The Specialist will also clarify plan language, internal evaluations, guidelines, etc., with referring company. Medical literature references will support the Specialist's assessment of functionality. The assessment will provide evidence for assurance that it is a valid claim for payment, or it will provide defensible evidence for a claim denial. For more info: www.nmrco.com/cpad.pdf

Wow! I have been so busy doing everything else - I haven't had time to work on my DIC claim / accrued benefits claim. But I got my first denial - so I feel like part of the crowd now. I guess a couple good things might have come from that. 1. They have played their "medical" hand first. So at least I know the angle they are taking at the moment. 2. By not developing the whole asbestos thing any more they have FINALLY acknowledged the claim for IN SERVICE INCURRENCE (that the cancer STARTED in the service) that they have totally ignored though it was the basis of my husband's initial claim and all his NOD, appeal stuff. They just kept acting like he hadn't mentioned it and they kept talking about the asbestos. Anyway - my husband sent in lots of medical information about the doubling time of adenocarcinoma -- the growth rates - etc. along with his letter from his treating oncologist that said the standard doubling time (time it takes for a tumor to double in size) is 180 days, and his inital handwritten form from his doctor on base showing that based on the doubling rate and size of tumor it would take around 15 years for a tumor to reach the size of my husbands. The VA asked for a medical opinion from a VA doc (I think) and all it says is that he looked at the SMRs and it was his opinion that it was less likely than not that the respiratory symptoms my husband had in service were related to his lung cancer as they were more likely related to respitory infections (or something like that-- I don;t have the letter right here). It seems like he totally ignored the fact that we never alleged the symptoms in service were cancer related. The whole basis of the claim was based on the growth rates. And we did point out that lung cancer is most often asymptomatic until it is late stage - and his medical records also state that my husband was asymptomatic when his cancer was discovered. So dang! If cancer is asymptomatic by its nature - and his medical records show he was asymptomatic but HAD cancer -- it is totally silly to ONLY address the symptoms -- as the VA opinion giver did. The good thing about that I would think is that it should be easy to blow that opinion away with a good medical opinion. You gotta wonder about the qualifications of a person who would take a disease that is known to be asympomatic -- be asked if based on medically sound principles it could have started in the service (especially with doctor's statements in the records about the doubling time of cancer) and still just generically address that the symptoms in service were probably not related to cancer -- without going beyond that to address whether the cancer started in service. But again, maybe the best thing about them going first is that they get a crap medical opinion that is easier to address. However, I have not read the actual opinion...so I don;t know. Does anyone know - since it takes 6 months or more to get a copy of anything from the VA --(Chicago) (Still waiting for records I requested last spring -- that my husband had requested the year before that). IS there a way to get a copy of JUST the medical report any sooner? Also - as the decision was made prior to the expiration of time for me to submit evidence that was requested -- when I send the evidence - can I ask for a reconsideration? (I guess I should also send a NOD). Free

Has anyone ever used the Evidence Based Medicine opinions. I was looking into that, but was not sure if anyone has experience with the VA with it. It seems like it would be right up the VA's ally - as it doesn't speculate or so much give opinions as it does a "based on the odds" type thing. I was thinking it might be good for my husband's claim (thus my claim) - as the in-service incurrance would be based on the fact that the 3 cm tumor found 2 years after he retired could not have grown NEARLY that fast -- based on the type of cancer he had. (Medical standards say that it would take about 17 years for pulmonary adenocarcinoma to reach that size). My husband entered the service in 1970 and retired in 1998. Cancer found in 2000. So I was figuring with all the odds - that an evidence based medicine report would show that the odds of him having the cancer for more than 2 years would certainly be more likely than not. I might also see if they could provide a report for --IF the VA acknowledges asbestos exposure for the 13 years he was an electrician - the odds of the asbetos exposure playing a role in the subsequent development of the lung cancer would be great. The only medical "evidence?" they have that the asbestos did not play a role in the development of the cancer is that the C&P doctor who did not see him stated that it was his opinion that my husband wasn't exposed to asbestos because he didn't have any record of occupational medical survillience or any unique medical conditions that would suggest asbestos exposure. He overlooked his Interstitial Lung Disease, he overlooked that the base medical records said likely exposure to asbestos, and he overlooked that the occupational screenings were not started until my husband was no longer an electrician. So has anyone at hadit ever used one of the evidence based medicine reports? Thanks Free

Also - keep in mind the BVA was VERY interested in your minister's lay statements. Those show an EXTREME change in your disposition between pre and post service. So with the wishy washy appears, seems, might be, could maybe opinion, an admission that you DID have anxiety in service, and the lay testimony that you were super person before the service - I would say you have a strong case. I don't think a maybe might have appeared suggested wishy washing medical opinion that is now too scared to mention the word personality disorder (most likely because they know they didn't diagnose it by adequate means) can over shadow the fact that there are no medical records of anxiety before service, excellent lay testimony of the change in you during the service, and the fact that they are dating it back TO the service (by trying to make it before) actually helps overcome the idea that it may have started after service. Free

Hi. Been busy as heck -- but popped in for a moment. They didn't just use "appears" Geez -- Is SUGGESTIVE and APPEARS the veterans anxiety MAY have preceeded the service. I am not sure this is better for you or not. Who wrote this. It sounds wishy washy to me -- like they are trying to give someone an out without going as far as saying more likely than not. But I guess wishy washy is better than strongly against. It COULD help - as they dropped the Personality Disorder thing --but that is a MAYBE -- because they used the word etiology is suggestive -- so are they leaving themselves the room to move full circle into a "the etiology" is actually the "persoanilty disorder... I.e. that the anxiety is caused by the personality disorder which preceeded the service. I am not sure - but what other etiology are they giving for your anxiety that would suggest it preceeded the service? Again - it looks like it is wishy washy enough that they are leaving it open to interpretation. It could be good - if it is interpreted that it is ONLY anxiety because if they deny you - you can go for in-service aggravation - and even the presumption of soundness. I think they should come right out and say what they think. However the fact that they didn't may work in your favor. SUGGESTIVE, APPEARS, and MAY have doesn't sound more likely then not to me. Free