Tim

Flores97, I was out of town since we last chatted. I thought my reply to your advice was submitted before I took my trip. I guess I hit the wrong key and lost my message to you. Nevertheless, let me try again. I warn you, my reply in long winded but I'm seeking your advice on how to properly proceed with my claim under appeal. So here we go, I'm just copying and pasteing what I wrote to you earlier. Flores97 Thank you for your advice. To answer your question, yes, I elected to select a DRO review of my appeal to increase my service connected disability rated as Coded as 5284, Foot Condition Other, described as "Residuals of foot injury." However, SHARE has them coded as 5284 "Degenerative Changes, Left Great Toe." Sir, I would like to ask you a few questions, than if you don't mind, provide you with further background to the horrors of my current claim. Regarding filing an Intent to File for lymphedema, should I accomplish this process online or through my VSO, Texas Veterans Commission? Regarding my IRIS inquiry for my claim that is under a DRO review, should it be conducted via phone or thru eBenefits? When I submit my inquiry should I discuss my claim from its origin, (VA's initial decision in April of 1990), or from my C&P exam in San Antonio, Texas on April 27, 2012? I believe it extremely important to assist me in arriving at a favorable on my behalf from the VA. I hope you are still sitting after reading what took place during the last three C&P examinations at San Antonio, Texas. If you are, please let me know it this statement should be forwarded and to whom. It was during the exam on April 27, 2012, when the examiner, Dr. Dinesman, asked me "Tell me about your arthritis in your left great toe?", and I replied, "I do not have arthritis in my left great toe and I was never aware that I had it while in the service." The physician responded, "Well, you are here today to have your left great toe examined for degenerative changes which is arthritis, so if you are saying that you don't have arthritis, than I'm closing your claim now!" In response to the examiner's statement, I said, "Sir, I was expecting to have my left foot examined to demonstrate that the current conditions from which I suffer (swelling, discoloration, venous insufficiency and severe pain) are the same residual disability complications/conditions that existed while I was in the Marines." I than said to Dr. Dinesman, "Here is my initial decision letter from the VA stating that service connection has been established for less than 10% for my left great toe condition and that my service records show treatment for left foot condition. Then their letter states there was no record of recurrence or complications during the rest of my service and no residual disability was indicated on your VA examination of November 21, 1989." I further stated, "that this statement was not accurate," and I showed him notes made in my military medical records where these same complications/conditions (swelling, discoloration, pain) resulting from the injury that I sustained to my left foot in May of 1982. The initial complications were indicated in my medical records on June 22, 1982, June 26, 1983, January 11, 1986, January 15, 1987, August 16, 1987, and February 26, 1988." Finally, I showed him where the VA letter also stated, "You may submit evidence at any time to establish residual disability. It must show a continuing disability from discharge to the present time." I then said, "Doctor, I am prepared today to provide you with the evidence to establish my residual disability." Dr. Dinesman said, "I think your initial claim was misdiagnosed. This is Texas, we get everything right in Texas. So take your evidence back to your VSO and resubmit your claim." Which I did that very day after I left the examination room. On my VA form 21-4138, I referenced the VA letter 362/CORE1/DLR dated April 12, 2012 and my C&P exam 4/27/2012. My statement provided the VA where they can find evidence from my medical records where the same residual complications/conditions from my service connected left foot injury were noted by VA physicians on November 4, 2009, March 30, 2010, May 13, 2010, November 14, 2011, and March 14, 2012. I also stated on the VA form, "The C&P Doctor will submit his own impressions of the above issue, he thinks I was misdiagnosed in the first place." Nevertheless, my claim was denied so my VSO told me to keep gathering evidence to establish a connection of your current medical conditions to the residuals from your initial service connected foot injury. I did just that and resubmitted a claim on March 4, 2014 for Foot Condition Other. In my statement, I wrote, "My discoloration remained recurrent, chronic and incapacitating upon discharge." Thru my statement, I then directed the VA where they can find evidence from entries made by VA physicians who diagnosed me with a swollen left foot, edema, discoloration, and probable venous insufficiency. VA physicians even prescribed me with compression stockings and Gabapentin and other medication to treat my chronic residual conditions from my service connected foot injury/infection." I ended my statement writing, "The main problem I have had over the years is that the C&P examiners and VA personnel are simply looking at my toe and do not take into account the residuals I developed as a result of the laceration to the toe and the development of cellulitis. The problems I suffer from are directly attributed to my injury in 1982. However, once again, my claim was denied but I believe the VA did not handle it properly for the reasons which I will highlight below. Here's what took place: When my wife and I arrived for my C&P exam at the VA's Frank Tejada Outpatient Clinic in San Antonio, Texas, on September 12, 2014, we were greeted by Mr. Clark, a Physician Assistant, who sat us down in his office and asked me to verify the purpose of my examination. Mr. Clark showed me an examination request that was different than what I had stated on my VA Form 21-4138. I requested to have the residuals of my service connected foot injury in my left foot evacuated for an increase of its current disability rating of 0%. Instead, the VA scheduled me for a C&P examination for an increase to my service connected Achilles Tendonitis injury along with Degenerative Changes to My Left Great Toe. Since my request was not honored, I refused to allow Mr. Clark to examine me. He than tried to call the rater's office in Houston, Texas, but was unable to reach him. Mr. Clark also stated that he did not have my medical records. I told him, "that I brought copies of both my military and VA medical records as evidence to support my claim. However, I will not submit them unless I am examined for the purpose that I submitted my claim for. The residuals of my service connected foot injury/infection is what I expected to be examined for today!" My statement upset Mr. Clark, so he walked across the hall to a doctor's office and closed the door behind him. A few minutes later, Mr. Clark returned to his office with the Doctor who told me, "Just have the exam completed, it's the same foot." I told the doctor politely, "Sir, I am refusing to be examined today because when I had went for my C&P exam in this same building on April 27, 2012 with Dr. Dinesman for what I thought was the same claim that I made for today's exam, the residuals of my service connected foot injury, he told me that the VA instead ordered him to conduct an exam for the arthritic changes to my left great toe." He I turn told me to resubmit my claim for the residual conditions from that foot injury/infection which I did." So sir, since I clearly followed Dr. Dinesman's instructions, I refuse to be examined for anything else but what I submitted my request for!" As soon as I said that, Mr. Clark left the office and returned shortly thereafter with the C&P Department's Administrative Officer, Mr. Edward Duenes. Mr. Duenes took my wife and I into his office where we discussed my challenge. After I explained to Mr. Duenes my frustration with the whole VA claims process and his C&P examiners, he attempted to call my assigned rater in Houston, Mr. Visokey, and have me speak with him. However, Mr. Visokey was unavailable, so Mr. Duenes left him a voice message. Mr. Duenes assured me that I would revive a personal phone call from Mr. Visokey and that I would be scheduled for another C&P exam to evaluate the residuals of my service connected foot injury. I thanked him, and then he asked to see the documentation that I had planned to submit as evidence. Mr. Duenes, reviewed my documentation that included medical options from doctors in Hawaii made in 2010 when I lived there. These private doctors stated that my prolonged swelling, discoloration, and pain are due to my prolonged cellulitis episode which occurred while I was in the Marines in the Philippines. I developed cellulitis when I stubbed my left great toe, experiencing a laceration on its tip and after entering contaminated water in the Philippine jungle, I incurred the severe infection. The residuals of that infection were prolonged swelling, discoloration, pain and diagnosed venous insufficiency, all of which are noted in my military medical records. Mr. Duenes then told me, "Tim, I don't know why Mr. Visa key hasn't approved your claim already based on the documents you presented me." He further stated, "I will keep your claim open rather than closing it so you won't have to submit a new claim, like you were told to do for this claim." After hearing his remarks, I felt much better about my upcoming exam and the results of my pending claim with the VA. Mr. Visokey did in fact call me and my C&P exam was rescheduled for September 26, 2014. Yet, my examination did not go well. When my wife and I arrived for the exam, to our shock, we were greeted by the same Physician Assistant, Mr. Clark. Right away, I was playing on unfair grounds, especially when Mr. Clark walked us by the same doctor, who I refused to have him examine my foot two weeks ago, and said to him, "This is the veteran I told you about!" Once we were inside Mr. Clark's office, the Physician Assistant asked me, "Have you straightened out the reason for your C&P exam with the rater, Mr. Visokey?" To which I replied, "I hope so, but you tell me Sir, since you have the request that he forwarded to you." I followed that up by asking Mr. Clark, "Well did he?" Mr. Clark's answer was, We will get to that later. I just want to know if you two worked it out?" I replied, "Sir, you know the answer to that question, why don't you let me know why I'm here today?" Mr. Clark didn't respond to my question but instead says, "Well he didn't send me your file, so I don't have any records to review on your case. Let me call him since he will be leaving his office in Houston in thirty minutes." It was 3 o'clock in the afternoon. I thought to myself, "Are you kidding me, these guys are something else!" I should of stopped him right then and there and requested to see Mr. Duenes. But I didn't, since I had all my documentation with me that I showed Mr. Duenes just two weeks earlier. My documentation included copies of my military records demonstrating my left foot injury, the subsequent sever skin infection that I incurred and the residuals of that infection; lymphadenitis in my left leg, swollen and discolored left foot and chronic pain. I also had in my possession, photographs of my left foot and diagnoses letters from physicians stated my current medical conditions and the origin of the residual conditions which are my in-service foot injury/infection. Given the statements that Mr. Duenes made to me and my wife two weeks ago and not wanting to return a third time for an exam, I felt comfortable giving the documentation to Mr. Clark to review on my behalf. So I did so, thinking this was the right move on my part. But it wasn't, as Mr. Clark completed discredited the evidence I provided him stating your condition isn't related to your military service and these doctors are not accurate in their findings!" My wife and I were appalled at his treatment of me. I said, "How could you make such claims as you don't even have my records and you haven't even looked at my foot!" "Photographs were taken of my swollen, discolored left foot in 2009 during my C&P exam in Hawaii and submitted to the VA. The conditions of my foot have not changed since 1982 when the injury and infection occurred." With that he asked me to sit down in an examining chair/table and went went to go get the doctor from across the hall. The fact that Mr. Clark did not have any of my records prior to the examination, nor did he request them in advance to review them except after I provided them to him should be deemed "inappropriate." Clearly, I was placed on unfair "playing grounds!" The cards were stacked against me! The doctor came in the examine room and told me to take off my VA prescribed compression stockings while he sat on a small stool in front of my feet. I followed his orders and the doctor starts forcefully twisting my left foot side to side and starts talking to Mr. Clark instead of me. The doctor tells Mr. Clark, "he doesn't have a problem with his left foot except that it swells up a little more than the right foot." By the time that I was examined, which was after siting in the office less than 15 minutes, both my feet turned bluish/purple and were swollen despite the use of compression stockings. Mr. Clark than tells the doctor that he can't complete his report until he orders studies to be done by at least Vascular. He then asks me, "Were vascular studies ever done?" I replied, "Yes sir, they were ordered by my VA primary care physicians and I even went to see the Orthopedic Clinic. Both the vascular and orthopedic physicians believe that I have a venous insufficiency condition, just like the military doctors diagnosed in 1982. My primary care doctor agrees with their opinions." To that, the doctor tells Mr. Clark, "I'm an orthopedic doctor and I don't see how they concluded that. They are wrong!" Mr. Clark replies to the doctor, "Ok, than I will order X-Rays to be taken." I in turn say, "Sir, what will the x-rays show you Sir? He replied, "Everything!" The physician assistant further stated, "I just got access to your medical records and I see you were treated in your VA records that you were treated by an orthopedic doctor in Hawaii for a growth on the bottom of your left foot. Is that correct?" I said, "That's correct, I had a small bruise on the bottom of my foot which was burned off." Mr. Clark replies, "Doctor, that's why his foot is discolored !" I said, ""That's inaccurate, my foot was chronically swollen, discolored and painful well before that treatment and various VA noted this fact prior to my visit to the orthopedic clinic. They diagnosed my residual conditions as either venous in nature or Raynaud Syndrome." The doctor just laughed and said to Mr. Clark, "Order the studies" and left the office. Afterwards, Mr. Clark walked my wife and I down to the X-Ray clinic at the Frank Tejada Outpatient Clinic where I had several x-rays taken of both my feet. Afterwards, my wife and I left the clinic totally frustrated and quite upset because of how the examination was conducted and with the feeling that my claim would be denied due to the way I was treated and how my evidence was discredited along with the examiner not having my military records. Mr. Clark also ordered a Bone Scan test which I underwent on October 3, 2014. Seeking to have my claim handled fairly and appropriately by the VA, I contacted Mr. Jorge Manuel Vallejo, an advocate representative from the "Fighting For Our Heroes Foundation," who after reviewing my case, made an appointment for me to meet with Senator Cornyn' South Central Texas/El Paso Deputy Regional Director, Mr. Jonathan Huhn on October 21, 2014 in San Antonio, Texas. I met with Mr. Huhn who reviewed my case and believed it should be forwarded to Senator Cornyn for action. So I completed a statement and letter for him that described the events surrounding my pending disability claim which was forwarded to Senator Cornyn on October 22, 2014. On December 16, 2014, I received a letter from Senator Cornyn regarding my claim informing me that my claim was finalized. In his letter, it states that the VA wrote him in an email dated December 16, 2014, stating "Senator Cornyn, Mr. McMahon received a $6,357.62 retro payment that was deposited into his account on November 13, 2014." The VA did not look very closely at my claim or file when they provided this information to Senator Cornyn. First of all, this payment had nothing to do with my pending claim for the increase of my current service connected 0% disability rating for "residuals of foot injury." These monies were owed me as back payment for my dependents from a favorable decision made by the VA on my behalf for a separate and different claim I submitted on September 14, 2009. In their letter addressed to me dated December 7, 2010, I was assigned a 10% rating for Cervical Spine, mild right C5-C6 foraminal stenosis and degenerative disc disease and an increase from 10% to 20% for Degenerative joint disease, thoracolumbar spine. It took the VA nearly three years to pay me the compensation for my dependents from those approved service connected disabilities. Clearly the VA misguided Senator Cornyn. I have tried my best in being patient with the C&P examiners and the entire VA claims process. It is my hope that the VA will review my claim and all the evidence that I have submitted to them, provide with an accurate evaluation, and approve my claim for an increase of disability rating that is higher than my current 0% rating for Code 5284; Residuals of Foot Injury. Both VA physicians and civilian doctors have examined my left foot and noted on numerous occasions that I suffer from chronic severe swelling, discoloration, pain, edema and venous insufficiency in my left foot. Their well documented notes indicate that my medical conditions are identical to the diagnosed residuals of my service connected foot injury/infection episode in May of 1982. Therefore, it is "as least likely as not," that my diagnosed medical condition are the by products of my service connected foot injury/infection and are residual disabilities of my foot injury. It is my hope that my claim will be resolved soon with a favorable decision made on my behalf. Thank you for your time considering my request. Respectfully submitted, Tim

Gentlemen, I apologize, as did not see your replies until now. Can I reply later this morning? Thank you for your advise and support. Tim

I have just two questions concerning my current claim that is under and Appeal with the VA. My questions are as follows: 1. Do I have sufficient documentation to support my claim under appeal? 2. Should I open a separate claim for lymphedema? Please allow me to introduce my scenario to help you provide me with the appropriate guidance. My topic of discussion is regarding my left foot condition which are residuals from a service connected injury/severe infection. I currently have a claim under appeal since November 17, 2014. I am requesting a De Novo Review w/a video teleconference hearing. My service connected condition is 5284 Foot Condition Other as stated in the 38 CFR. I wrote in my disagreement. "The problems I am experiencing today are due to the foot trauma I had in service. The C&P examiner did not have my military records to review when opinioning whether or not my current condition is related to my in service condition." Here is the background to my claim: Just prior to discharge from the Marines, I submitted my initial claim to the VA on September 16, 1989, through the Disabled American Veterans Office, San Diego, California, for several conditions to include my left foot condition. On April 20, 1990, I received a service connected disability rating of 0%, coded as 5284 “Degenerative Changes, Great Left Toe, with history of injury". Service connection was established for my left great toe disability but the VA stated that it wasn't compensated because, "It is not causing you problems at this time." However, I believe that the VA misdiagnosed my disability and assigned me with the wrong rating because my VA medical records list the same service connected disability as diagnostic code 5284; Foot condition other, residuals of foot injury. Herein lays my ongoing problem with the VA that I have had over the years. My decision letter from the VA dated April 20, 1990 also states, "Your service records show treatment for left foot condition during military service. However, there is no record of recurrence or complication during the rest of your service and no residual disability was indicated on your VA examination on November 21, 1989." This is not true, as my military medical records indicate otherwise in notes made to my military medical records on May 13, 1982, June 22, 1982, June 26, 1983, January 11, 1986, and January 15, 1987. Furthermore, my left foot was never examined during the C&P exam. The C&P examiner never asked me to take off the sock on my left foot. The VA letter further wrote, “You may submit evidence at any time to establish residual disability. It must show a continuing disability from discharge to the present time." When I have submitted several claims to increase my disability from 0%, the C&P examiners and Department of Veterans Affairs personnel are simply looking at my left toe and do not take into account the in-service documented residuals I have developed as a result of the laceration to the left toe and the development of severe cellulitis that occurred in May of 1982 while serving in the USMC in the Philippines. Since May of 1982, I have suffered edema, swelling, discoloration, and pain in my left foot and leg and at least from 2005, the swelling and discoloration is bilateral; both left and right feet. These health conditions are the by-products of my service connected infection. I have attempted several times to prove residual disability but the VA keeps denying me and wants me to prove that my degenerative changes in my left great toe have worsened. I do not have degenerative changes in my left toe; my issues are the chronic health conditions of edema, swelling, discoloration, pain in my left foot and leg with lymphedema and venous insufficiency. In fact, the VA knows that I have lymphedema and they have been treating me for lymphedema since October 9, 2015 through the use of medication and the FlexiTouch System (http://www.tactilemedical.com/products/flexitouch/). I have attempted to file disability claims as advised by several VSOs under cellulitis, venous insufficiency and last year under code 5284 Foot Condition other. All of these claims have been denied. This is where I find myself again today with my current claim that is under appeal with the VA. However, during one of my C&P exams in Honolulu, Hawaii, a VA physician cited the swelling and discoloration and edema in my feet and even took photographs for submission to the rater with his notes. He wrote, “Pt had bluish discoloration of lt great toe. Lt great toe decreased ROM secondary to scarring from infection. Affects work climbing in and out of ships. Affects daily activities. Yet, my claim to increase the rating under Code 5284 from 0% was still denied. On March 30, 2010, during another C&P exam in Honolulu, the physician wrote the following notes, “Post service treatment records show left edema & venous insufficiency left leg. Lower left extremity; mild duskiness with dangling the left leg." Poor circulation but present pulses in the left lower extremity." I also have submitted to the VA two letters from physicians as evidence in hope to support my claim of chronic residual disability which are by products of my service connected infection. The first letter is from the Rheumatologist that the VA outsourced me to for care of my left foot and leg. He wrote on May 13, 2010, "your symptoms are due to a combination of 2 issues, the first is venous insufficiency with prolong color changes in the leg due to previous cellulities with sepis. Second, is mild left sciotics (pinched nerve in lower back)." The second letter is from my Kaiser Permanente physician, who wrote, “Veteran has been under my care since January 2009 and has been having pain, swelling, and discoloration of left leg since 1982. This all started after a severe skin infection which penetrated into the deeper tissues which required intravenous antibiotics and prolonged hospitalization of about 3 months while he was serving in the United States Marine Corps. The veteran has persistent pain, discoloration and swelling in left leg when standing or sittings for long periods. I consulted vascular surgery to evaluate patient for possible problems in arteriovenous lymphatic systems. Vascular surgery assessed the patient and with the history of prolonged infection that it may have caused scarring of the lymphatic system which can be the reason for the pain, discoloration and swelling of the left leg. Lastly, I submitted a letter To the VA from a vascular surgery physician regarding my chronic swelling, discoloration and pain in my left foot and leg. After reviewing my medical records, he conducted his initial evaluation that included venous ultrasound assessment of my lower extremities. His evaluation noted that the lymph nodes in my left upper thigh/groin area were visualized and not seen on the right. On October 15, 2015, he wrote, “The veteran has chronic pain and swelling in his left foot and lower leg due to lymphedema. Following my evaluation and review of his medical records, I find the veteran is disabled due to the lymphedema condition as a result of the injury he initially sustained while in the U.S. Marine Corps during May of 1982. It is more likely than not that the physical trauma of chronic swelling, discoloration and pain that the veteran currently suffers are the residuals of prolonged cellulitis with lymphadenitis that occurred during the veteran's military service as noted in his medical records." His letter also contained a photograph of my left foot and his evaluations. Here is the history of my foot injury: On or about May 7, 1982, while on active duty in the Marine Corps, I stubbed my big left toe, experiencing a laceration and the wound was treated with native herbs and penicillin powder. Afterwards, I entered into tropical contaminated water in the jungles of the Philippines. Soon thereafter, my left foot leg became swollen and I was in severe pain. I developed erythema all over the dorsum of my left foot and tenderness that ran from the dorsum of my left foot to my left leg, up to the inguinal area, with a palpable tender lymph node in my upper left thigh/groin area. For several days, I experienced severe chills and fever accompanied by swelling in my left foot and leg. I was seen in the Emergency Room at the United States Air Force Regional Medical Center, Clark Air Force Base, Philippines. I was given Bacitracin ointment for the lesion on my left big toe and some antibiotic capsules and released. However, the severe pain and swelling persisted in my left foot and leg and I sought admission into the hospital the following day. On May 13, 1982, I was admitted into the hospital with the initial diagnosis of cellulitis, left foot, with lymphadenitis; inflammation of the lymph nodes. Damage to the lymph system cannot be repaired. I was given intravenous antibiotics for the severe skin infection (cellulitis) which penetrated into the deeper tissues of my left foot and leg. The cellulitis was resolved but the prolonged, severe skin infection had penetrated into deeper tissues of my foot and leg causing scarring of my lymphatic system, resulting in the chronic lymphedema symptoms of swelling, discoloration, and pain in my left foot and leg. (Lymphedema cannot be cured but with appropriate treatment (intravenous antibiotics), it can be controlled.) My left foot turned purple upon standing and the Dermatologist at the Air Force hospital diagnosed my condition as erysipelas; an acute bacterial infection, skin disease, in the upper layer of my left foot. (Erysipelas has risk factors that include problems with drainage through the veins and lymph system.) After remaining hospitalized for thirty-two days, I was then discharged for air-evacuation to Balboa Naval Hospital, San Diego, California for further treatment of my left foot and leg. My diagnosis upon discharge from the Air Force Hospital on June 22, 1982 was cellulitis, left foot with lymphadenitis and Erysipelas. Upon arrival in San Diego, I remained hospitalized due to persistent swelling and discoloration of my left foot. Studies and observations of my foot and leg were conducted. I was seen by physicians at Balboa Naval Hospital from the Internal Medicine, Vascular and Orthopedic Clinics. Rapid development of edema in my left foot was evident. All doctors noted that that my left foot turned blue/purple with severe smoothing immediately upon standing and sitting. Military medical records on June 25, 1982 noted “bluing of distal digits when hanging leg off exam table, edema in left foot resolved when elevated but reoccurred quickly.” My toes did not touch the floor due to the persistent swelling in my left foot. A Naval Vascular physician diagnosed my incapacitating edema condition as Venous Insufficiency following my prolonged history of severe cellulitis. Edema, swelling, discoloration, and venous insufficiency of my left foot were diagnosed by military physicians as residuals of my injury/infection. These residuals from my prolonged cellulitis infection persisted throughout my remaining active duty service in the United State Marine Corps and are noted in my medical records. So, do you think that I have sufficient documentation to support my claim under appeal? And, should I open a separate claim for lymphedema? Your expertise is most appreciated. Thank you. Best regards, Tim

Thanks for responding Navy4Life. Let me correct myself, my claim for service connected compensation was received by the VA on March 24, 2014. Since the VA had continued to look at the degenerative changes in my great left toe and denied me twice, my VSO decided to take a different approach. Since it was documented in my military medical records that I was diagnosed with Venous insufficiency, he submitted the claim with the medical description as follows: left leg insufficiency with bilateral venous reflux. The VA doctors at Audie Murphy Hospital had diagnosed me with this condition. On October 30, 2014, the VA denied me for this condition stating that it was previously rated as left leg cellulitis, severer vascular disease which was not service connected. In that same letter, the VA determined that my service connected condition for degenerative changes, left great toe, hasn't changed. The VA received my written disagreement on November 17, 2014.Under the guidance of my VSO, I listed my disagreements on my statement dated November 7, 2014 as follows: "Degenerative Changes, Great Toe - I am not claiming venous insufficiency as a new condition. My service connected condition is 5284 Foot Condition Other as stated in the 38 CFR. The problems I am experiencing today are due to the foot trauma I had in service. The C&P examiner did not have my military records to review when opinioning whether or not my current condition is related to my in service condition." Then on November 4, 2015, my VSO added my nexus letter and supporting documentation regarding my diagnosed lymphedema condition. He never mentioned lymphedema on my signed and submitted VA Form 21-4138. Rather, he wrote this statement, "Please see attached lay statement and Doctors letter concerning my appeal for my foot condition." I believe that I have "connected the dots" regarding my lymphedema condition the letter from my physician. Do you agree? If so, should I submit a claim for lymphedema by itself? It is documented in my military medical records that i was diagnosed with lymphadenitis.

I have never filed a claim for Lymphedema because my VSO advised me against it even after I submitted him evidence that I have. He just added it to my claim that it is under appeal. My claim was denied on March 24, 2015. On November 17, 2014, the VA received my written disagreement. I filed a claim for increase of my 0% disability rating under Code 5284 sometime in late 2011 and had my C&P exam for my claim on 4/27/12. The C&P examiner asked me if I had degenerative arthritis in my left great toe. I told him, "No I did not." So he told me to go back to my VSO and file a different claim since he believed that I was misdiagnosed by the VA in the first place. I did go back and my VSO filed it under venous insufficiency and it was denied. But it was denied on March 24, stating " that my degenerative changes in my left toe hasn't changed. I appealed their decision because I am not claiming that venous insufficiency as a new condition But rather as a residual of my left foot condition which is rated as "degenerative changes, left great toe. On November 4, 2015 I submitted a letter To the VA from a vascular surgery physician regarding my chronic swelling, discoloration and pain in my left foot and leg. After reviewing my medical records, he conducted his initial evaluation that included venous ultrasound assessment of my lower extremities. His evaluation noted that the lymph nodes in my left upper thigh/groin area were visualized and not seen on the right. On October 15, 2015, he wrote, “The veteran has chronic pain and swelling in his left foot and lower leg due to lymphedema. Following my evaluation and review of his medical records, I find the veteran is disabled due to the lymphedema condition as a result of the injury he initially sustained while in the U.S. Marine Corps during May of 1982. It is more likely than not that the physical trauma of chronic swelling, discoloration and pain that the veteran currently suffers are the residuals of prolonged cellulitis with lymphadenitis that occurred during the veteran's military service as noted in his medical records." His letter also contained a photograph of my left foot and his evaluations. In fact, the VA knows that I have lymphedema and they have been treating me for lymphedema since October 9, 2015 through the use of medication and the FlexiTouch System (http://www.tactilemedical.com/products/flexitouch/). Should I file a claim now for lymphedema?

I have just two questions which I list below concerning my current claim with the VA. But first, allow me to introduce my scenario. Just prior to discharge from the Marines, I submitted my initial claim to the VA on September 16, 1989, through the Disabled American Veterans Office, San Diego, California, for several conditions to include my left foot condition. My topic of discussion is regarding my left foot condition. I currently have a claim under appeal since November 17, 2014. I am requesting a De Novo Review w/a video teleconference hearing. My service connected condition is 5284 Foot Condition Other as stated in the 38 CFR. The problems I am experiencing today are due to the foot trauma I had in service. The C&P examiner did not have my military records to review when opinioning whether or not my current condition is related to my in service condition. On April 20, 1990, I received a service connected disability rating of 0%, coded as 5284 “Degenerative Changes, Great Left Toe, with history of injury". Service connection was established for my left great toe disability but the VA stated that it wasn't compensated because, "It is not causing you problems at this time." However, I believe that the VA misdiagnosed my disability and assigned me with the wrong rating because my VA medical records list the same service connected disability as diagnostic code 5284; Foot condition other, residuals of foot injury. Herein lies my ongoing problem with the VA that I have had over the years. My decision letter from the VA dated April 20, 1990 also states, "Your service records show treatment for left foot condition during military service. However, there is no record of recurrence or complication during the rest of your service and no residual disability was indicated on your VA examination on November 21, 1989." This is not true, as my military medical records indicate otherwise in notes made to my military medical records on May 13, 1982, June 22, 1982, June 26, 1983, January 11, 1986, and January 15, 1987. Furthermore, my left foot was never examined during the C&P exam. The C&P examiner never asked me to take off the sock on my left foot. The VA letter further wrote, " You may submit evidence at any time to establish residual disability. It must show a continuing disability from discharge to the present time." When I have submitted several claims to increase my disability from 0%, the C&P examiners and Department of Veterans Affairs personnel are simply looking at my left toe and do not take into account the in-service documented residuals I have developed as a result of the laceration to the left toe and the development of severe cellulitis that occurred in May of 1982 while serving in the USMC in the Philippines. Since May of 1982, I have suffered edema, swelling, discoloration, and pain in my left foot and leg and at least from 2005, the swelling and discoloration in bilateral; both left and right feet. These health conditions are by products of my service connected infection. I have attempted this several times to prove residual disability but the VA keeps denying me and wants me to prove that my degenerative changes in my left great toe have worsened. I do not have degenerative changes in my left toe, my issues are the chronic health conditions of edema, swelling, discoloration, pain in my left foot and leg with lymphedema and venous insufficiency. In fact, the VA knows that I have lymphedema and are treating me for since October 9, 2015 with the use of the FlexiTouch System (http://www.tactilemedical.com/products/flexitouch/). I have attempted to file disability claims as advised by several VSOs under cellulitis, venous insufficiency and last year under code 5284 Foot Condition other. All of these claims have been denied. However, during my C&P exams in Honolulu, Hawaii, the physician cited the swelling and discoloration and edema in my feet and even took photographs for submission to the rater with his notes. He wrote, " Pt had bluish discoloration of lt great toe. Lt great toe decreased ROM secondary to scarring from infection. Affects work climbing in and out of ships. Affects daily activities. Yet my claim to increase the rating under Code 5284 from 0% was still denied. On March 30, 2010, during another C&P exam in Honolulu, they physician wrote the following notes, " Post service treatment records show left edema & venous insufficiency left leg. Lower left extremity; mild duskiness with dangling the left leg." Poor circulation but present pulses in the left lower extremity." I also have submitted two letters from physicians in hope to support my claim of chronic residual disability which are by products of my service connected infection. The first letter is from the Rheumatologist that the Va outsourced me to for care of my left foot and leg. He wrote on May 13, 2010, "your symptoms are due to a combination of 2 issues, the first is venous insufficiency with prolong color changes in the leg due to previous cellulities with sepis. Second, is mild left sciotics (pinched nerve in lower back)." The second letter is from my Kaiser Permanente physician, who wrote, " Veteran has been under my care since January 2009 and has been having pain, swelling, and discoloration of left leg since 1982. This all started after a severe skin infection which penetrated into the deeper tissues which required intravenous antibiotics and prolonged hospitalization of about 3 months while he was serving in the United States Marine Corps. The veteran has persistent pain, discoloration and swelling in left leg when standing or sittings for long periods. I consulted vascular surgery to evaluate patient for possible problems in ateriovenous lymphatic systems. Vascular surgery assessed the patient and with the history of prolonged infection that it may have caused scarring of the lymphatic system which can be the reason for the pain, discoloration and swelling of the left leg. Lastly, I submitted a letter To the VA from a vascular surgery physician regarding my chronic swelling, discoloration and pain in my left foot and leg. After reviewing my medical records, he conducted his initial evaluation that included venous ultrasound assessment of my lower extremities. His evaluation noted that the lymph nodes in my left upper thigh/groin area were visualized and not seen on the right. On October 15, 2015, he wrote, " The veteran has chronic pain and swelling in his left foot and lower leg due to lymphedema. Following my evaluation and review of his medical records, I find the veteran is disabled due to the lymphedema condition as a result of the injury he initially sustained while in the U.S. Marine Corps during May of 1982. It is more likely than not that the physical trauma of chronic swelling, discoloration and pain that the veteran currently suffers are the residuals of prolonged cellulitis with lympadenitis that occurred during the veteran's military service as noted in his medical records." His letter also contained a photograph of my left foot and his evaluations. So my questions are as follows: 1. Do I have sufficient documentation to support my claim under appeal? 2. Should I open a separate claim for lymphedema? Here is the history of my foot injury: On or about May 7, 1982, while on active duty in the Marine Corps, I stubbed my big left toe, experiencing a laceration and the wound was treated with native herbs and penicillin powder. Afterwards, I entered into tropical contaminated water in the jungles of the Philippines. Soon thereafter, my left foot leg became swollen and I was in severe pain. I developed erythema all over the dorsum of my left foot and tenderness that ran from the dorsum of my left foot to my left leg, up to the inguinal area, with a palpable tender lymph node in my upper left thigh/groin area. For several days, I experience severe chills and fever accompanied by swelling in my left foot and leg. I was seen in the Emergency Room at the United States Air Force Regional Medical Center, Clark Air Force Base, Philippines. I was given Bacitracin ointment for the lesion on my left big toe and some antibiotic capsules and released. However, the severe pain and swelling persisted in my left foot and leg and I sought admission into the hospital the following day. On May 13, 1982, I was admitted into the hospital with the initial diagnosis of cellulitis, left foot, with lymphadenitis; inflammation of the lymph nodes. Damage to the lymph system cannot be repaired. I was given intravenous antibiotics for the severe skin infection (cellulitis) which penetrated into the deeper tissues of my left foot and leg. The cellulitis was resolved but the prolonged, severe skin infection had penetrated into deeper tissues of my foot and leg causing scarring of my lymphatic system, resulting in the chronic lymphedema symptoms of swelling, discoloration, and pain in my left foot and leg. Lymphedema cannot be cured but with appropriate treatment (intravenous antibiotics), it can be controlled. My left foot turned purple upon standing and the Dermatologist at the Air Force hospital diagnosed my condition as erysipelas; an acute bacterial infection, skin disease, in the upper layer of my left foot. Erysipelas has risk factors that include problems with drainage through the veins and lymph system. After remaining hospitalized for thirty-two days, I was then discharged for air-evacuation to Balboa Naval Hospital, San Diego, California for further treatment of my left foot and leg. My diagnosis upon discharge from the Air Force Hospital on June 22, 1982 was cellulitis, left foot with lymphadenitis and Erysipelas. Upon arrival in San Diego, I remained hospitalized due to persistent swelling and discoloration of my left foot. Studies and observations of my foot and leg were conducted. I was seen by physicians at Balboa Naval Hospital from the Internal Medicine, Vascular and Orthopedic Clinics. Rapid development of edema in my left foot was evident. All doctors noted that that my left foot turned blue/purple with severe smoothing immediately upon standing and sitting. Military medical records on June 25, 1982 noted “bluing of distal digits when hanging leg off exam table, edema in left foot resolved when elevated but reoccurred quickly.” My toes did not touch the floor due to the persistent swelling in my left foot. A Naval Vascular physician diagnosed my incapacitating edema condition as Venous Insufficiency following my prolonged history of severe cellulitis. Edema, swelling, discoloration, and venous insufficiency of my left foot were diagnosed by military physicians as residuals of my injury/infection. These residuals from my prolonged cellulitis infection persisted throughout my remaining active duty service in the United State Marine Corps and are noted in my medical records.