fiasco2g

Well that sounds better than what I was told on the phone from the VA. They said the same people who do claims for disability do the dependency. Shows what great communication the VA has. Thanks.

How long did it take you guys to get your dependents added? Ebenefits has a completion date on my dependent claim of 2019. WTH? That should be automated since they have all my dependents SSN. This is crazy.

Yes I included my entrance exam as well and my hearing was good then. They just got this wrong and apparently did not read my claim or just had to deny something. maybe they have a mandate from their supervisor to deny at least one thing to see if we will appeal the decision. That is pure speculation but at this point a reasonable one given all the veterans who have had problems. Thanks for the replies

Well I included the fast 10-35 letter which my mos is rated Moderate in the claim. I also included my personal statement which i will paste below. It seems clear to me they screwed this up because their own letter says moderate or high should get connected. They say the ear doctor from my C&P said it was from before I joined the military because i did have tubes in ears when little but I clearly told them to their face my ears started ringing while deployed in iraq. Oh well I guess I need to figure out how to do a CUE since I did not see a link on ebennies. I -------- joined the US Army on ---------, and received an Honorable Discharge on -------. I was stationed with ----------------, Fort Bragg NC 28310 when I was deployed to Iraqi from ------ – ---------. My job was convoy security gun truck commander out of Baghdad International Airport (Biap). My hearing got worse while deployed due small arms fire, IED, RPG’s, etc. I also started getting ringing in my ears during this same deployment timeframe. I was around loud radars, generators, and artillery guns due to my normal job. The ringing in my ears is a daily event that can have several severe occurrences to many. It is different everyday but impossible to work or concentrate when it happens. This tinnitus started during my deployment to Iraq as a convoy security gun truck commander. I have included as attachments in my fdc claim entrance hearing test results, radar repairer MOS hearing lost probability chart fast letter 10-35, this personal statement, combat action badge, dd-214, and the va hospital audiology exam results from ----------- in which I was told that I need a hearing aid and there is nothing they can do about the tinnitus. I certify under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and belief.

So mine was about 167 days from actual filing (8-21-16) that is probably what they go by then they combined my second claim with the first so that may have slowed it down a little. I think I had my ducks in a row from all the great info here before filing and some stuff still did not go through. I guess I will need to look into a NOD or CUE for the tinnitus/hearing.

Well got the BBE and got 70% PTSD, 40% Fibromyalgia, Denied hearing loss, Denied Tinnitus. Also got some backpay but it was without my dependents so maybe after that goes through I will get the rest. Thanks to everyone that helped. I will need to continue to fight them on the tinnitus because the examiner had an agenda it looked like to me. Had all the evidence of combat action badge, iraq service, MOS that was considered medium-high for sound, etc. Seems like it would have been a slam dunk but you never know when an examiner will just say it is not service connected and the Rating officer just rolls with that. But anyway it has started out pretty good so cant complain. First intent to file was on 1-18-16 Filed first claim 8-21-16 PTSD, hearing loss, tinnitus 10-6-16 second intent to file 12-4-16 Claim for fibromyalgia (had to wait for diagnosis so a second claim was needed) 1-29-17 Ebenefits went to preparation for decision 2-2-17 Ebenefits went to pending decision approval 2-3-17 Ebenefits went to Decision letter sent and under disability my 70%Ptsd and 40% Fibro showed up for 80% combined rating 2-7-17 BBE arrived and direct deposit of retroactive backpay ( for a single person) Thanks again

Thanks. Was able to do it on ebennies when part of my claim went through.

I filed an intent to file 1-18-16 then filed a claim 8-21-16. New DX Oct 2016 so filed another intent to file 10-6-16. Claim filed for this 12-4-16. Both claims have been combined and I have a decision letter on its way. On ebenefits it say I have 70% for fist claim and 40% for second claim. 80% combined. Effective date of first is 1-18-16 and second is 10-6-16. Since this was combined and the second claim was filed within one year of the first intent to file should it have the same effective date of 1-18-16 or is this correct? Maybe it is I just do not know and would like to file to get it changed it it is wrong. Could not anything about this specific issue. Thank you.

Well I finally got somewhere at least. 80% combined rating so far but I guess part of my stuff went back to gathering of evidence. My tinnitus must be the problem even though that should be simple one. I did get 70% PTSD and 40% Fibromyalgia. Ebenefits just updated today with that info so when should I receive a BBE and payment? So is part of it going back to gathering of evidence normal? Thanks to everyone who has helped out on the site as I continue to work through this.

Thank you I will wait to see what they say. Then will continue to follow through until all information and rating is correct.

Thanks for the reply but, it does not take a doctor to realize that every medicine and treatment tried does not help my symptoms. You sound like a disgruntled VA employee in my opinion. So dry your eyes snowflake.

Hello. Cant remember if I put my dependents on my FDC? Is that part of the process or will they need to be added after getting SC? Thank you

Works now. Crazy how it goes down and the phone number they had did not work as well.

Well I guess everyone is as confused by this as I am. Hopefully they will give me a decision soon and I can share.

Anybody else getting this error when they try to login to ebennies. Error Code [50]: We have located your DEERS record; however, it appears there may be invalid information on file. You may contact the DMDC/DEERS Support Office (DSO) at 800-538-9552 for assistance. To best assist you, please call when you are at a computer if possible. What the heck does this mean? I never changed any deers stuff. And the phone number does not work

Ok. Was able to get the exam pasted above. Looks like we did 4 DBQ's i thought it was one.

Hello. I went for my fibromyalgia C&P exam and just got the results from myhealthvet. It looks like it was several DBQ's including my back now. Can someone explain these results. I only see one error which is my pain is refractory to medicine. They have my pain is constant but then state NO to the refractory to medicine question. But anyways what do you guys think. IT IS LONG. Sorry. Attached & pasted MHV Fibro.docx CONFIDENTIAL Page 4 of 31 VA Notes Source: VA Last Updated: 30 Jan 2017 @ 1321 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Date/Time: 18 Jan 2017 @ 0800 Note Title: C&P GENERAL MEDICAL - AMIE/CAPRI Location: Fayetteville NC VAMC Signed By: Co-signed By: Date/Time Signed: 25 Jan 2017 @ 1740 Note LOCAL TITLE: C&P GENERAL MEDICAL - AMIE/CAPRI STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 18, 2017@08:00 ENTRY DATE: JAN 25, 2017@17:40:38 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* Name of patient/Veteran: 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 CONFIDENTIAL Page 5 of 31 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 2. Medical History ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided e. Hearing loss, tinnitus and ear: No answer provided f. Sinus, nose, throat, dental and oral: No answer provided g. Breast: No answer provided h. Respiratory: No answer provided i. Cardiovascular: No answer provided j. Digestive and abdominal wall: No answer provided k. Kidney and urinary tract: No answer provided l. Reproductive: No answer provided m. Musculoskeletal: The following conditions have been reported Spine: Back (Thoracolumbar Spine) Conditions Miscellaneous musculoskeletal: Fibromyalgia CONFIDENTIAL Page 6 of 31 n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: No answer provided q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [X] Yes [ ] No Diagnosis #1: Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 Name of Questionnaire: DBQ Neuro Fibromyalgia 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- CONFIDENTIAL Page 7 of 31 The E-VBMs, CPRS, JlV, Veteran's history and documents carried in by the patient were all reviewed and carefully considered during this exam. Diagnosis: 1. Fibromyalgia, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. ************************************************************************** The examination was initiated and completed by provider Debra Barton FNP, and administratively reviewed and closed by clinical lead Dr. June Roberts. **************************************************************************** Fibromyalgia Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV CONFIDENTIAL Page 8 of 31 Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with fibromyalgia? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Fibromyalgia ICD code: M79.7 Date of diagnosis: approx. 2007 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's fibromyalgia condition: The Veteran has a history of active military service in the United States Army highest rank E5 and a Admits to service in Iraq 6/18/04-5/28/05. He presents for Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and CONFIDENTIAL Page 9 of 31 other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. b. Is continuous medication required for control of fibr omyalgia symptoms? [X] Yes [ ] No If yes, list only those medications required for the Veteran's fibromyalgia condition: Gabapentin c. Is the Veteran currently undergoing treatment for this condition? [X] Yes [ ] No If yes, describe: He has been advised on a exercise program and search into a biofeedback program. d. Are the Veteran's fibromyalgia symptoms refractory to therapy? [ ] Yes [X] No 3. Findings, signs and symptoms ------------------------------- Does the Veteran currently have any findings, signs or symptoms attributable to fibromyalgia? [X] Yes [ ] No a. Findings, signs and symptoms (check all that apply): [X] Widespread musculoskeletal pain [X] Stiffness [X] Sleep disturbances [X] Paresthesias [X] Headache [X] Depression For all checked conditions, describe: Veteran has had a sleep study and has milds OSA, sleep efficiency was 70%. He has headaches bitemporal that may be associated with his sinus issues. He has parathesias when he tries to sleep. He has been diagnosed with PTSD. b. Frequency of fibromyalgia symptoms (check all that apply): [X] Constant or nearly constant CONFIDENTIAL Page 10 of 31 [X] Often precipitated by environmental or emotional stress or overexertion If checked, describe: Overexertion and extreme cold will exacerbate his symptoms. c. Does the Veteran have tender points (trigger points) for pain present? [X] Yes [ ] No [X] All bilaterally [X] Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Second rib: at second costochondral junction If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Occiput: at suboccipital muscle insertion If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Trapezius muscle: midpoint of upper border If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Supraspinatus muscle: above medial border of the scapular spine If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Lateral epicondyle: 2 cm distal to lateral epicondyle If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Gluteal: at upper outer quadrant of buttocks If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Greater trochanter: posterior to greater trochanteric prominence If checked, indicate side: [ ] Right [ ] Left [X] Both [X] Knee: medial joint line If checked, indicate side: [ ] Right [ ] Left [X] Both 4. Other pertinent physical findings, complications, conditions, signs, symptoms and scars CONFIDENTIAL Page 11 of 31 ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No 5. Diagnostic testing --------------------- Are there any significant diagnostic test findings and/or results? [ ] Yes [X] No 6. Functional impact --------------------- Does the Veteran's fibromyalgia impact his or her ability to work? [X] Yes [ ] No If yes, describe impact of the Veteran's fibromyalgia, providing one or more examples: Veteran is not able to climb stairs, descend stairs or bend (squat) repeatedly and has to ask others to cover those tasks for him. He is not able to do repetitive task or he starts hurting and has to stop. The Veteran is unable to participate in heavy physical prolonged labor. The Fibromyalgia does not preclude participation in sedentary employment. 7. Remarks, if any: ------------------- The examination was initiated and completed by provider DEBRA BARTON AND REVIEWED BY DESL LEAD AND CLOSED. **************************************************************************** Non-degenerative Arthritis (including inflammatory, autoimmune crystalline and infectious arthritis) and dysbaric osteonecrosis Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No CONFIDENTIAL Page 12 of 31 ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: chronic multi-symptom illness(pain throughout his body) b. Select diagnoses associated with the claimed condition(s): No response provided CONFIDENTIAL Page 13 of 31 c. Comments (if any): Diagnosis Degenerative Disc Disease Lumbar Spine L5/S1 date of diagnosis 6/6/2016 ICD 10 M43.06 d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's inflammatory, autoimmune, crystalline or infectious arthritis or Dysbaric Osteonecrosis. (brief summary) The Veteran has a history of active military service in the United States Army highest rank E5 Admits to service in Iraq 6/18/04-5/28/05. He presents for a Gulf War Examination. While serving in SWA the Veteran admits to exposure to fumes from burning pits, blowing sand, extreme weather fluctions, and reported being exposed to hostile enemy fire. He admits to a disability pattern due to fibromyalgia, arthritis of the lumbar spine( claimed as medically unexplained chronic multisymptom illness). Veteran reports he has had diffuse pain throughout his "joints" and other locations since he got out of the military. He has had X-rays of the wrist, ankle, knees and back to evaluate for degenerative an inflammatory diseases and has had extensive blood workups. He was finally sent for a Rheumatololgy evaluation on 10/3/16 at the Durham VAMC. There he was diagnosis with Fibromyalgia. Review of the radiographs of the wrist, ankle, and knees showed no osseus abnormality. The lumbar spine showe mild L5-S1 disc disease. b. Does the Veteran require continuous use of medication for the arthritis condition? [ ] Yes [X] No c. Has the Veteran lost weight due to arthritis condition? [ ] Yes [X] No d. Does the Veteran have anemia due to the arthritis condition? [ ] Yes [X] No 3. Joint Involvement -------------------- a. Does the Veteran have pain (with or without joint movement) attributable to this arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint CONFIDENTIAL Page 14 of 31 For all checked joints, describe involvement: Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. b. Does the Veteran have any limitation of joint movement attributable to the arthritis condition? [X] Yes [ ] No If yes, indicate affected joints [ ] Cervical spine [X] Thoracolumbar spine [ ] Sacroiliac joint For all checked joints describe limitation of movement: The Veteran has problems with back flexion, extension, RL bending and LL bending. c. Does the Veteran have any joint deformities attributable to the arthritis condition? [ ] Yes [X] No d. Comments No response provided 4. Systemic involvement other than joints ----------------------------------------- a. Does the Veteran have any involvement of any systems, other than joints, attributable to this arthritis condition? [ ] Yes [X] No b. Comments: No response provided 5. Incapacitating and non-incapacitating exacerbations ------------------------------------------------------ a. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating? [ ] Yes [X] No b. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating? [X] Yes [ ] No If yes, indicate frequency of incapacitating exacerbations per year (on average): [ ] 0 [ ] 1 [X] 2 [ ] 3 [ ] 4 or more Indicate the total duration of incapacitation over the past 12 months: [X] < 1 week [ ] 1 week to < 2 weeks [ ] 2 weeks to < 4 weeks [ ] 4 weeks to < 6 weeks [ ] 6 weeks or more Date of most recent incapacitating exacerbation: approx. 11/2016 CONFIDENTIAL Page 15 of 31 Duration of most recent incapacitating exacerbation: less than one day Describe incapacitating exacerbation: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 on a 0-10 scale. c. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating? [ ] Yes [X] No d. Is the Veteran's arthritis manifested by weight loss and anemia productive of severe impairment of health? [ ] Yes [X] No e. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods? [ ] Yes [X] No f. Is the Veteran's arthritis manifested by symptoms combinations productive of definite impairment of health objectively supported by examination findings? [ ] Yes [X] No g. Comments: No response provided 6. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No c. Comments, if any: No response provided 7. Assistive devices -------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided CONFIDENTIAL Page 16 of 31 8. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's arthritis condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 9. Diagnostic testing --------------------- a. Have imaging studies been performed and are the results available? [X] Yes [ ] No [X] X-ray Area(s) imaged: Lumbar spine Date: 6/6/2016 Results: L5-S1 degenerative disc diseae b. Have laboratory studies been performed? [X] Yes [ ] No If yes, check all that apply: [X] Erythrocyte sedimentation rate (ESR) Date of test: 6/2/16 Results: 3 [X] C-reactive protein Date of test: 6/2/16 Results: < 2.9 [X] Rheumatoid factor (RF) Date of test: 9/19/13 Results: <10 [X] CBC Date of test: 6/2/16 Hemoglobin: 14.5 Hematocrit: 41.2 White blood cell count: 5.69 Platelets: 243 [X] Other, specify: CCP IgG Ab Date of test: 6/2/16 Results: <16 c. Has the Veteran had a joint aspiration or synovial fluid analysis? [ ] Yes [X] No d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)? [ ] Yes [X] No CONFIDENTIAL Page 17 of 31 e. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No f. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: Report: Lumbosacral spine Clinical data: pain Comparison: none. Findings: Alignment: Normal. Vertebral bodies: Normal. Intervertebral disc spaces: Mild narrowing L5-S1. Facet Joints: Normal. Soft Tissues: Normal. Other: Impression: 1. Mild L5-S1 disc disease. Veteran has Degenerative disc disease, not a Rheumatic disease. The Veteran has palpable spasms of the lumbar spine which correlates to the degenerative changes on the lumbar spine x-ray. 10. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He is unable to participate in prolonge heavy physical labor. The diagnosed lumbar spine condition does not preclude participation in sedentary employment. 11. Remarks, if any: -------------------- Veteran has degenerative arthritic conditions and Fibromyalgia; not inflammatory arthritic conditions. **************************************************************************** Back (Thoracolumbar Spine) Conditions CONFIDENTIAL Page 18 of 31 Disability Benefits Questionnaire Name of patient/Veteran Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia CONFIDENTIAL Page 19 of 31 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Degenerative disc disease L5-S1 ICD code: M43.06 Date of diagnosis: 6/6/2016 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Veteran suffers from low back pain that he has had since he was in the service. He states that carrying heavy rucks and rapelling out of helicopters contributed to his back issues. He was classified as a radar repairman but when he was sent to Iraq he served as a gunner on a gun truck and was involed in lifting heavy ammo. His pain in the lower back is a 5 on a 0-10 scale. He started complaining of low back pain and pain in some of his other joints. In 2007 he was sent to a Polytrauma clinic in Wilkes Barre, PA, VAMC. There he was evaluated and diagnosed with fibromyalgia and degenerative joint/disc disease of the low back and it was opined that it was related to his service experience. However, the Veteran does not recall the diagnosis or any follow-up. He has complained of the low back pain and chronic polyarthralgias since enrolling at the FVAMC in September of 2013. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: Veteran states he has fallen to the ground with extreme pain. It happens infrequently but when it happens it is violent. Pain is a 10 CONFIDENTIAL Page 20 of 31 on a 0-10 scale. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. He does not lift over 30 pounds. He does not play sports or enjoy things with his children as his back will act up. He is unable to ride in a car for a long period of time without his back flaring up. 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [ ] All normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0 to 90): 0 to 70 degrees Extension (0 to 30): 0 to 25 degrees Right Lateral Flexion (0 to 30): 0 to 25 degrees Left Lateral Flexion (0 to 30): 0 to 25 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 25 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Veteran is unable to lift more than 30 lbs. Description of pain (select best response): Pain noted on exam but does not result in/cause functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion Is there evidence of pain with weight bearing? [ ] Yes [X] No Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Veteran has spasm in the lumbosacral area that is tender. CONFIDENTIAL Page 21 of 31 b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance ability over Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain and or endurance are limiting the Veteran's functional without repeated use over time. Based on the clinical exam today and the Veteran's statements it is plausible to concur that time he would be more limited. I am not able to determine actual degrees of decreased ROM however. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No CONFIDENTIAL Page 22 of 31 If the examination is not being conducted during a flare-up: [X] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Weakness, Lack of endurance Able to describe in terms of range of motion: [ ] Yes [X] No If no, please describe: Pain, weakness and or endurance are limiting the Veteran's functional ability without being in a flare-up. Based on the clinical exam today and the Veteran's statements it is plausible to concur that during a flare-up he would be more limited. I am not able to determine actual degrees of decreased ROM however. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: Musle spasm present in the lumbosacral paraspinals related to the way the Veteran hols his back. Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Provide description and/or etiology: Guarding of the lower back that results in muscle spasm. CONFIDENTIAL Page 23 of 31 f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Interference with sitting, Interference with standing Please describe additional contributing factors of disability: Veteran is not able to sit or stand for extended periods of time without experiencing more pain and spasms. 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent CONFIDENTIAL Page 24 of 31 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 9. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities CONFIDENTIAL Page 25 of 31 ---------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [ ] Yes [X] No 12. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 13. Remaining effective function of the extremities --------------------------------------------------- Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided CONFIDENTIAL Page 26 of 31 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [X] Yes [ ] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: Veteran is unable to lift more than 30 lbs. He can't sit or stand for extended periods of time. He can otherwise perform his job duties. 17. Remarks, if any: -------------------- There was a thorough review of E-BVMs, CPRS and JLV as well as a focused history from the Veteran regarding his Southwest Asia Service. The Veteran claimed an unexplained chronic multi-symptom illness of pain throughout his body which included low back pain. The low back bain is diagnosed as 1. Degenerative Arthritis of the Spine. M43.06. It is a disease with a clear and specific etiology and diagnosis that is separate from the Fibromyalgia. The Degenerative Arthritis of The Spine is at least as likely as not (50 % probability) that it is related to the Veteran's Military Service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by a Rehab specialist who opined the back problems were related to his military service. The Veteran did have negative x-rays at that time, however in June of 2016 his X-ray is indicating degenerative changes of the lumbar spine. The Veteran reports job duty changes while CONFIDENTIAL Page 27 of 31 serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): JLV Evidence Comments: Branch Army DD214 EAD 6//3/98 RAD 9/5/2005 Rank SGT E5 Served in Iraq 06/18/04-05/28/05 Convoy security, blowing sand, burn pits. He was stationed near Bagdad International Airport. 6/17/99 STR-- Normal exam no complaints of back or other joint pain. 10/24/07 MTR Wilkes Barr PA Polytrauma Clinic Dx. with Fibromyalgia and low back pain, examiner was of the opinion it was related to military service. CONFIDENTIAL Page 28 of 31 10/3/16 MTR Durham VAMC Rheumatology Consult, dx with Fibromyalgia MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ General Medical Gulf War: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. Please examine and evaluate this Veteran with Southwest Asia service for any chronic disability pattern. Please review the claims file as part of your evaluation and state that it was reviewed. The Veteran has claimed a disability pattern related to Medically unexplained chronic multi-symptom illness (pain throughout his body). Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (1) an undiagnosed illness; or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, then no medical opinion or rationale is required as these conditions are presumed to be caused by service in the Southwest Asia theater of operations. If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a CONFIDENTIAL Page 29 of 31 medical opinion, with supporting rational, as to whether it is "at least as likely as not" that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. POTENTIALLY RELEVANT EVIDENCE: NOTE: Your (examiner) review of the record is NOT restricted to the evidence listed below. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Tab D (Federal treatment record in VBMS): VETERAN PROVIDED HIS COPY OF TREATMENT FROM THE VA dated 12/04/2016 Tab B (Veteran's statement in VBMS): Veteran provided statement on how his pain is reflected throughout his entire body. dated 12/04/2016 Tab A (DD Form 214 in VBMS): DD 214, Iraqi Campaign Medal noted dated 12/04/2016 Tab C (Federal treatment record in VBMS): CAPRI MEDICAL FROM THE DURHAM, FAYETTEVILLE, AND WILKES-BARRE VAMC dated 12/16/2016 Please direct any questions regarding this request to: Mike Theriot 8810 Rio San Diego Dr San Diego, CA 92108 Phone number: 6194005515 Email: mike.theriot@va.gov b. Indicate type of exam for which opinion has been requested: DBQ FIBRO TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The Veteran was diagnosed with Fibromyalgia in approximately 2007 after serving in SWA in 6/18/04-5/28/05. He underwent an extensive evaluation and inflammatory/other rheumatological disorders were ruled out. He meets the diagnostic criteria for fibromyalgia. It is not an undiagnosed illness. It is not a disease with a clear and specific etiology. However, it CONFIDENTIAL Page 30 of 31 is a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. I am unable to state with any degree of certainty which environmental hazards could have caused the disease. ************************************************************************* RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Contention: medically unexplained chronic multisymptom illness ( pain through out his body) b. Indicate type of exam for which opinion has been requested: DBQ ARTH/BACK TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The contention of medically unexplained chronic multisymptom illness ( pain through out his body) diagnosed as degenerative arthritis of the lumbar spine(also see fibromyalgia template). The diagnosis of djd lumbar spine is not an undiagnosed illness, and is not a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, and did not result from exposure to environmental hazard due to service in SWA. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. ************************************************************************* Contention: Lumbar Spine Condition due to active military service. Medical Opinion: It is as least as likely as not a 50/50% probability that the Veteran claimed medically unexplained chronic multisymptom illness ( pain through out his body), diagnosed as degenerative disc disease lumbar spine was incurred in or resulted from active military service. Rationale: The Veteran did not have any back issues when he entered active duty. His entrance exam is negative for problems. He was released from active duty in 2005. In 2007 he was examined and diagnosed with low back pain in a VAMC by CONFIDENTIAL Page 31 of 31 a Rehab specialist who opined the back problems were related to his military service. The Veteran reports job duty changes while serving in Iraq that included heavy lifting of ammo and moving guns on the gun trucks as he was assigned to security details. The degerative arthritis of the lumbar spine has a clear and specific etiology. The Veteran was a combat Veteran, and participated in required PT, field exercised, and repelled out of helicopters. All of which could put increased stress on the lumbar spine, and many of the exercises are carried out with rucks on you back. Thus opined as above. THIS DOCUMENT WAS ORIGINALLY INITIATED BY: BARTON,DEBRA A /es/ June L ROBERTS MD Signed: 01/25/2017 17:40 END OF MY HEALTHEVET PERSONAL INFORMATION REPORT

Congrats. How long did it take from the time you filed?

Well they still say they do not have them. Talked to both places and they confirmed they uploaded both. One was the same day and one the next day. Why cant the VA rep on the phone see the information as soon as it is uploaded. The person on the phone says the claims office in winston salem has to upload it into the system for them(phone rep) to see. If it is in one VA system for the claims department why does it not just go into a system everyone can see including me on the bluebutton. The va is stupid!!!!

Hello all. Any idea how to get LHI (contractor) C&P exam results? The VA over the phone says they never received the DBQ's which have now pasted the due date. Called both places I had the exams at and left a voicemail. The day of exams both places said they would be sent in within 24 hours of exam so I guess they have already sent them but to who? LHI or the VA? If anyone has any knowledge of the actual process from LHI contractor to the VA and timeframe that would be great. Thanks for the help. My exams were completed several weeks ago so they have had plenty of time to upload them online.

Yes. So far on my FDC they have asked for and waited 30 plus days for info I uploaded from the get go. I tried to send a message through IRIS so they would not wait the complete time since I uploaded all files including va records but they never responded. The FDC was filed on 8-21-16 and after 30 days it now says it is awaiting a va facility record but not which one and that time has (10-12-16) ended but the status still says gathering evidence. Maybe in the next few weeks I will get exam dates or something.

Thanks, just the answer I was looking for. A seperate FDC for fibromyalgia.

I have a FDC in progress right now (PTSD and hearing/tinnitus) but have a new diagnosis this week of fibromyalgia from the VA rheumatologist that was not filed yet. Can I add this to my claim without hurting the FDC status or just wait until this one is complete and start a new one for Fibromyalgia. Since it is a presumptive does the claim need to be filed before 31 Dec 2016 or just the diagnosis before this date (which I should have in writing once myhealth blue button updates in a few days). Thanks.

Does anyone know if I can get a c&p exam if I click the request a decision button? I just want them to know I have no more uploads and they can continue on without waiting the full thirty days for document uploads. I thought fdc meant fully developed. But i still want exams.

Hello. My status shows that I need to turn in a VA Form 21-4142a for my vet center records so I uploaded it. It says I have like 30 days and the status shows awaiting review. I already uploaded all my current vet center records so why should I be delayed so they can request them? Can I just contact them through iris to see if they can skip this step since I have uploaded my vet center file when I filed my FDC? Also will the status remain as gathering evidence until exams are scheduled and completed? I wish they just had a little more detail on each step. Do not want to be held up until 9/28 just so they can request a record I already uploaded. Thanks.