[CP conducted without veteran.]

Thanks Navy04. I have been receiving MH treatment from VA for about 3 years. I am currently unemployed. Denial letter states records and forms never received when I know they were received.

Can some of the moderators answer a question. What is best a DRO Review, Appeal or could I submit a CUE?

 

[CP conducted without veteran.]

New cp didn't answer SGE. just PTSD has gotten worse. The claim was an FDC for IU (new) and increase for PTSD/MST. I submitted.claim with VOC rehab infeasible letter but RO is stating this is not new material and evidence. My last IU claim did not have letter. I have sent for cfile before I appeal.

 

 

 

 

[CP conducted without veteran.]

Update. New CP conducted. Dr said PTSD conditions has gotten worse. VSO  informed claim has been Denied because evidence submitted was not considered new and material to refute the previously denial. How can a voc rehab not feasible for service connected disability Ietter I submitted  not be considered new and material evidence?

[CP conducted without veteran.]

Thanks Berta for your quick response. I agree this is inadequate exam. It's from an exam  for IU they  did last year that lasted for only 5 minutes. the CP doctor did not conduct a thorough exam due to I had breast cancer surgery two days prior. So he told me to go home and he would complete exam. No I do not receive SSDI. But I do have a letter form Voc Rehab that states I am not feasible for Voc Rehab due to SC and NSC disabilities. I am currently medically retired. I am taking meds for sleep disturbance and other mental disorders. I applied for TDIU after given the 70% rating I was working at the time. 

 

[CP conducted without veteran.]

Sorry for the long post but need some insight. I filed a claim IU in June 2015. I looked at my my healthvet file and found this. It states a CP Exam but I was not present as I read further it was seem like a medical opinion from a CP Exam I had in December of last year. Can someone take a look at it and give some insight into what the outcome may be? 

This is an addendum to Dr. ??? PTSD C&P evaluation of 12/12/2014, Per VBA request of 11/24/2015. Dr. ???is no longer available to complete the addendum so it was assigned to this writer. The relevant portion of form 2507 is copied below: Please have examiner ?????. provide an addendum to the examination he or she conducted on the Veteran on 12//1/2/2014. Please provide the following clarification: Please state whether or not the Veteran's service connected post traumatic stress disorder precludes her from physical or sedentary employment. DBQ PSYCH PTSD Review: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. The Veteran is service connected for post traumatic stress disorder (also claimed as sleep disturbances) which is currently evaluated at 70%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder. Additional remarks for the examiner: Veteran is claiming TDIU as a result of her service connected post traumatic stress disorder disability as well as several nonservice connected disabilities. ***Please comment on the effect of the Veteran's service connected disabilities on his or her ability to function in an occupational environment and describe any identified functional limitations. Please refrain from opining on if the veteran is unemployable or employable; instead focus and reflect on the functional impairments and how these impairments impacts occupational and employment activities. This addendum is based upon the veteran's condition around the time of Dr. ??? evaluation, determined to the best of this writer's ability, based upon his report and available contemporary documentation in the medical record. Her condition may have worsened in the ensuing 50 weeks. CPRS records indicate that this veteran was suffering from Recurrent Major Depression around the time of Dr.???? evaluation, and had been at least sporadically since 2006. She was also diagnosed with prolonged bereavement. The severity of the MDD had been rated as Mild to Moderate about 3 weeks before Dr. ???? saw her. Thus, it would have been appropriate for a MH evaluator to attempt to determine what portion of the veteran's reported level of occupational and social impairment was due to the PTSD, to the Bereavement, and to the MDD. An attempt to do so post hoc is complicated by the fact that the veteran was and apparently still is experiencing auditory and visual hallucinations that have variously been described as depressive phenomena, and as feaures of unresolved bereavement over her sister's sudden death in 2006. Because the treating psychiatrist opined that "[Anti-psychotic medication will not be prescribed because] her AVH [Auditory/Visual Hallucinations] are comforting and associated with bereavement," writer will not consider those as being contributory to veteran's reported level of social/occupational impairment. Conservatively estimating that 20% of the reported impairment can be attributed to MDD, which appears not to be service-connected, writer will review reported PTSD symptoms in attempting to opine whether these in and of themselves would have impacted employment.  Veteran was found to be somewhat withdrawn, and to be emotionally isolated from others. She had irritability, problems with concentration, and sleep disturbance. She had anxiety, suspiciousness, disturbance of motivation and mood, problems establishing relationships, and poor tolerance for stress. She avoided thinking about her trauma. These symptoms would have been expected to affect employability in that veteran would have been expected to have difficulty working in an environment that was stressful, put her in contact with large numbers of others, and put more than moderate demands on her ability to concentrate and remain alert. She would not do well in a situation within which she was expected to take initiative or to self-motivate. However, sedentary occupations within a low-stress, low social contact environment, with modest productivity demands, probably would not have been precluded by the PTSD symptoms mentioned above. Furthermore, even jobs that are modestly physically demanding would not have been precluded solely by the PTSD symptoms, albeit of course there were other, potentially limiting non-psychiatric impairments present as well. Writer opines that her capacity to work in an environment optimized for her PTSD symptoms would have been moderately impaired but not absolutely precluded.

[Va Pension?]

I checked my ebenefits letter and noticed this on my benefits summary 

You are receiving non-service connected pension:

Yes

 

Is this a error? I am confused.

[IU Help]

I am appealing the SSDI decision. SS is saying i cant do me previous job but that i can do some work. I will be adding the cancer diagnose to my next claim. I was stationed in fort Mcclellan AL and I was in Operation Desert Storm so i will be applying for environmental hazard. Thanks for the suggestion concerning my c file I will be requesting it to see what is in my files.

[IU Help]

Yes I was denied the first time. I have applied for social security and was denied. I am currently medical retired from federal government due to cancer and other disabilties. I wasnt when I applied the first time.

[IU Help]

I am currently receiving 70% for PTSD with no established secondary conditions.

[IU Help]

Listed below is the letter I received from Voc Rehab. Will it help with a IU claim?

I performed a comprehensive evaluation of the above referenced veteran’s current situation
as it applies to the potential to complete a program of rehabilitation services and profit from
these services by returning to suitable gainful employment. As a matter of course, every
evaluation includes a thorough examination of the veteran’s records including available
medical documentation. All other issues concerning reasonable feasibility for a program
of services are explored.

 The above referenced veteran is determined to be currently infeasible to participate in a
program of rehabilitation services and profit from these services. This determination is
based on the available information which indicates her service connected disabling
conditions and associated problems secondary to these medical conditions preclude
successful participation in a program of rehabilitation services or the identification of a
suitable occupational goal.

This information is submitted to the Adjudication Division in accordance with the
provisions of M 28-1, Part II, and M 28-2, Part I, Ch 4, Para. 4.03(a) which refers to advising
your office of medical infeasibility of a veteran rated less than 100% disabled.

[Rating For Ptsd C & P]

----------

1. Diagnostic Summary

---------------------

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

--------------------

a. Diagnosis #1: PTSD due to MST and combat

ICD code: 309.81

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Deferred to medical

records

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

No response provided.

d. Axis V - Current global assessment of functioning (GAF) score: 65

3. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

4. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment due to mild or transient symptoms

which decrease work efficiency and ability to perform occupational

tasks only during periods of significant stress, or; symptoms

controlled by medication

b. For the indicated level of occupational and social impairment, is it

possible to differentiate what portion of the occupational and social

impairment indicated above is caused by each mental disorder?

[ ] Yes [ ] No [X] No other mental disorder has been diagnosed

c. If a diagnosis of TBI exists, is it possible to differentiate what

portion

of the occupational and social impairment indicated above is caused by

the

TBI?

[ ] Yes [ ] No [X] No diagnosis of TBI

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence review

------------------

a. Records reviewed (check all that apply):

[X] Claims folder (C-file):

[X] Yes

[ ] No

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

3. Stressors

------------

a. Stressor #1: In total darkness in the bunker Gulf war.

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

Is the stressor related to the Veteran's fear of hostile military

or

terrorist activity?

[X] Yes [ ] No

b. Stressor #2: MST (Patient later stated this should be #1)

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

Is the stressor related to the Veteran's fear of hostile military

or

terrorist activity?

[X] Yes [ ] No

c. Stressor #3: We were close to where that skud missle hit.

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

Is the stressor related to the Veteran's fear of hostile military

or

terrorist activity?

[X] Yes [ ] No

4. PTSD Diagnostic Criteria

---------------------------

a. Please check criteria used for establishing the current PTSD diagnosis.

The diagnostic criteria for PTSD, referred to as Criteria A-F, are from

the Diagnostic and Statistical Manual of Mental Disorders, 4th edition

(DSM-IV).

Criterion A: The Veteran has been exposed to a traumatic event where both

of the following were present:

[X] The Veteran experienced, witnessed or was confronted with an event

that involved actual or threatened death or serious injury, or a

threat to the physical integrity of self or others.

[X] The Veteran's response involved intense fear, helplessness or

horror.

Criterion B: The traumatic event is persistently reexperienced in 1 or

more of the following ways:

[X] Recurrent and distressing recollections of the event, including

images, thoughts or perceptions

[X] Recurrent distressing dreams of the event

Criterion C: Persistent avoidance of stimuli associated with the trauma

and numbing of general responsiveness (not present before

the

trauma), as indicated by 3 or more of the following:

[X] Efforts to avoid activities, places or people that arouse

recollections of the trauma

[X] Feeling of detachment or estrangement from others

[X] Restricted range of affect (e.g., unable to have loving feelings)

Criterion D: Persistent symptoms of increased arousal, not present before

the trauma, as indicated by 2 or more of the following:

[X] Difficulty falling or staying asleep

[X] Irritability or outbursts of anger

[X] Hypervigilance

Criterion E:

[X] The duration of the symptoms described above in Criteria B, C and

D

is more than 1 month.

Criterion F:

[X] The PTSD symptoms described above cause clinically significant

distress or impairment in social, occupational, or other important

areas of functioning.

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:

[X] Stressor #1

[X] Stressor #2

[X] Stressor #3

5. Symptoms

-----------

For VA rating purposes,

check all symptoms that apply to the Veterans

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[X] Flattened affect

[X] Suicidal ideation

6. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[X] Yes [ ] No

If yes, describe:

Panic attacks are twice weekly.

Lack of trust issues.

7. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

8. Remarks, if any

------------------

Currently taking 150 mg Zoloft

Medical Opinion 1

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

C-file was reviewed.

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

1. Definitions

--------------

Not applicable

2. Restatement of requested opinion

-----------------------------------

a. Insert requested opinion from general remarks:

Is the Veteran's post traumatic stress disorder at least as likely as

not

(50 percent or greater probability) incurred in or caused by active

duty where she served in Southwest Asia?

b. Indicate type of exam for which opinion has been requested (e.g. Skin

Diseases):

PTSD

3. Medical opinion for direct service connection

------------------------------------------------

a. [X] The claimed condition was at least as likely as not (50 percent or

greater probability) incurred in or caused by the claimed in-service

injury, event, or illness. Provide rationale in section c.

b. [ ] The claimed condition was less likely than not (less than 50 percent

probability) incurred in or caused by the claimed in-service injury,

event, or illness. Provide rationale in section c.

c. Rationale: Patient experienced both MST as well as combat related

trauma.

Personal physical assault, and long term fear for loss of

life and lives of others has been associated with the

development of emotional pathologies meeting DSM-IV

diagnostic

criteria.

4. Medical opinion for secondary service connection

---------------------------------------------------

Not applicable

5. Medical opinion for aggravation of a condition that existed prior to

service

-------------------------------------------------------------------------------

Not applicable

6. Medical opinion for aggravation of a nonservice connected condition by a

service connected condition

---------------------------------------------------------------------------

Not applicable

7. Opinion regarding conflicting medical evidence

-------------------------------------------------

[C & P Help]

Here is the DBQ from my C and P

Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Larynx and Pharynx
DBQ

Indicate Indicate method to obtain medical information to complete this
document:

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because
the existing medical evidence provided sufficient information on which
to
prepare the DBQ and such an examination will likely provide no
additional
relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination

Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[X] Yes[ ] No

If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:

c-file reviewed.

SECTION I: Diagnosis:
---------------------
Does the Veteran now have or has he/she ever been diagnosed with a sinus,
nose, throat, larynx, or pharynx condition? (This is the condition the
Veteran is claiming or for which an exam has been requested)
[X] Yes [ ] No

[X] Other, specify:

Other diagnosis #1: NORMAL THROAT EXAMINATION
ICD code: --
Date of diagnosis: 08/2013

SECTION II: Medical history
---------------------------

--Army, 1987-1991, honorable discharge, PERSIAN GULF WAR.
--Stationed at Fort Gordon. In 1991, evaluated in sick call for vomiting,
etc, was diagnosed with dehydration, stomach and pharyngitis, hospitalized
at
Eisenhower Hospital in Augusta, GA.

SINCE POST MILITARY DISCHARGE, the veteran stated that her throat
condition has worsen.

--CURRENT SYMPTOMS: throat is irritated (burns) alot, scratchy, with flareups

(1-2 times months) difficulty with swallowing. Don't know whether it is her
acid reflux bothering her or not.
--Has followed up with Dr. Taube in Warner Robins, GA and was treated twice
for throat infections, last treated 01/2013.

--SURGERY: None.

--CURRENT MEDICATIONS/THERAPY:
--Treat over the counter Mouth Rinse (Listerine) or cough drops.
--RANITIDINE HCL 150MG TAB
TAKE ONE TABLET BY MOUTH EVERY DAY AS NEEDED FOR STOMACH
OMEPRAZOLE 20MG EC CAP
TAKE ONE CAPSULE BY MOUTH TWICE A DAY, BEFORE MEALS FOR STOMACH


SECTION III: Nose, throat, larynx or pharynx conditions
-------------------------------------------------------
Does the Veteran have any of the following nose, throat, larynx or pharynx
conditions?
[X] Yes [ ] No

[X] Larynx or pharynx condition

3. Larynx and pharynx conditions
--------------------------------
a. Does the Veteran have chronic laryngitis?
[ ] Yes [X] No

If yes, does the Veteran have any of the following symptoms due to
chronic
laryngitis?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Hoarseness
If checked, describe frequency:

[ ] Inflammation of vocal cords or mucous membrane
[ ] Thickening or nodules of vocal cords
[ ] Submucous infiltration of vocal cords
[ ] Vocal cord polyps
[ ] Other, describe:

b. Has the Veteran had a laryngectomy?
[ ] Yes [X] No

If yes, specify:

[ ] Total laryngectomy
[ ] Partial
laryngectomy
If checked, does the Veteran have any residuals of the partial
laryngectomy?
[ ] Yes [ ] No

If yes, describe:

c. Does the Veteran have laryngeal stenosis, including residuals of
laryngeal
trauma (unilateral or bilateral)?
[ ] Yes [ ] No

If yes, assess for upper airway obstruction with pulmonary function
testing, to include Flow-Volume Loop, and provide results in Diagnostic
testing section.

d. Does the Veteran have complete organic aphonia?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Constant inability to speak above a whisper
[ ] Constant inability to communicate by speech
[ ] Other, describe:

e. Does veteran have incomplete organic aphonia?
[ ] Yes [ ] No

If yes, check all that apply:

[ ] Hoarseness
If checked, describe frequency:

[ ] Inflammation of vocal cords or mucous membrane
[ ] Thickening or nodules of vocal cords
[ ] Submucous infiltration of vocal cords
[ ] Vocal cord polyps
[ ] Other, describe:

f. Has the Veteran had a permanent tracheostomy?
[ ] Yes [ ] No

If yes, describe reason for tracheostomy and potential for decannulation:

g. Has the Veteran had an injury to the pharynx?
[ ] Yes [ ] No

If yes, check all findings, signs and symptoms that apply:

[ ] Stricture or obstruction of the pharynx or nasopharynx
[ ] Absence of the soft palate secondary to trauma
[ ] Absence of the soft palate secondary to chemical burn
[ ] Absence of the soft palate secondary to granulomatous disease
[ ] Paralysis of the soft palate with swallowing difficulty (nasal
regurgitation) and speech impairment
[ ] Other, describe:

h. Does the Veteran have vocal cord paralysis or any other pharyngeal or
laryngeal conditions?
[ ] Yes [X] No

If yes, describe:

6. Other pertinent physical findings, scars, complications, conditions,
signs
and/or symptoms

-----------------------------------------------------------------------------

RATIONALE FOR OPINION GIVEN:
Based on examination and all available documentation, veteran has a
NORMAL THROAT/PHARYNX EXAMINATION (claimed as pharyngitis). A
pharyngitis/throat condition is corroborated as having occurred during
service with complaint of neck pain, elevated temperature, nasal
congestion, examination showed neck to be supple with positive
tenderness
over trapezius, erythema pharyngeal without exudate or tender
adenopathy,
positive tenderness over maxillary, lungs bibasilar, complain of
headache without aura, diagnosed with ARDS 07/19/1999). Military
findings
are inconsistent with current clinical presentation of a normal
throat/pharynx examination. Examiner also stated my condition impact my ability to work

[C & P Help]

Hello Hadit. This site is so helpful and gives great advice. I recently received a copy of my C & P and need some advice on if or not I will receive a SC rating based on the Medical Opinion given below.

RATIONALE FOR OPINION GIVEN:
Based on examination and all available documentation, veteran has a
NORMAL THROAT/PHARYNX EXAMINATION (claimed as pharyngitis). A
pharyngitis/throat condition is corroborated as having occurred during
service with complaint of neck pain, elevated temperature, nasal
congestion, examination showed neck to be supple with positive
tenderness
over trapezius, erythema pharyngeal without exudate or tender
adenopathy,
positive tenderness over maxillary, lungs bibasilar, complain of
headache without aura, diagnosed with ARDS 07/19/1999). Military
findings
are inconsistent with current clinical presentation of a normal
throat/pharynx examination. Examiner also stated my condition impact my ability to work.
.