doc25

Pyramiding is a no-no with va disability claims. at least a likely and not due to service connected condition? Please clarify. Did you mean, "at least as likely as not" due to service connected condition? Because if you did; you probably received a favorable nexus of opinion that will substantiate your claim for "Secondary-Service connection". If you meant, "less likely than not" due to service connected condition that'll be an unfavorable nexus of opinion. On the issue of hypertension, if the increase is granted at 10% You'll be rated like this: 30% hypertensive disease, LVH then an arrow below that: 30%Cardiac arrhythmia, irregular heartbeats 10% hypertension You'll be rated 56%, rounded up to 60%. All indications point to a favorable decision, but you'll have to wait until you receive the decision letter. Best wishes on your claim. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Here is another secondary condition you might consider. SLEEP APNEA; as secondary to hypertensive heart disease. Do you have Sleep Apnea diagnosed with a documented "medically necessary" CPAP or other assistive breathing device. ("Medically Necessary" must be documented by the prescribing Dr. otherwise nowadays the VA will automatically deny the claim.) Sleep Apnea with a medically necessary CPAP is rated 50% Look at this appealed Sleep Apnea claim, as secondary to hypertensive heart disease that was granted. https://www.va.gov/vetapp15/Files4/1534763.txt If you do not have Sleep Apnea, but develop it later on, it could be linked to your heart disease.

Recently, there's been a discussion on the forum, about using medical journals, articles, or other medical literature. In my opinion, at least as likely as not, they do add "some" weight as "competent lay evidence": A veteran that can CONNECT THE DOTS , in my own opinion, shall be deemed competent to provide medical literature relevant to a condition being claimed. Now, medical literature; such as, journals, articles, research studies, etc is medical literature that uses fact based medical evidence, using what many, not all people understand as the scientific method. The research is done by qualified and competent medical professionals. Otherwise, they wouldn't put their name and reputation on the line? Therefore, a veteran that is competent can provide competent medical literature; as lay evidence. But there's a catch. If you're going to use medical literature, be sure to submit the same journal, article, study,etc. that you submitted on ebenefits or a VSO, DAV, or other veterans organization;to your IN MY OPINION Dr. or the C&P examiner. Basically, what you're doing is doing the heavy lifting for them already. And use the one that is the most relevent, compelling and probative to your claim. Also, in your lay evidence provide a table of contents that's in chronological order. (Ratings schedulers don't have the time to give your claim due diligence. You have to consider that one Ratings Scheduler can be assigned up to 1,500 claims and still get another 1,000 on top of that.) Unfortunately, the burden of proof, falls on us as veterans. Even though it shouldn't. I'll follow up with more info later today. In the meantime, here is an appealed claim for Sleep Apnea, Secondary to Allergic Rhinitis that was granted. https://www.va.gov/vetapp07/files3/0721554.txt read through all of it and give secondary connection some thought. I hope this info provides you some insight.

I will give it a go. Clearly and unmistakably there are a number of conditions present with your spine. The good thing is that you have a SERVICE-CONNECTED DISABILITY and some of your conditions may be rated as Secondary conditions to your lumbosacral strain. (Secondary conditions are rated separately , in most cases).The VBA or Veteran's Benefits Administration rates spinal conditions by the general rating formula and incapacitating episodes. This website can better explain in depth http://www.militarydisabilitymadeeasy.com/thespine.html#form Look for the codes that best describe your conditions and see if they'll fall under either the general rating formula or incapacitating episodes. For example: Let's say you have two or more of the conditions that would be rated under the general rating formula. The Ratings Scheduler might put those conditions together to avoid pyramiding, like this- "Lumbosacral Strain with osteopenia and vertebrae fractures" (This is just an example, don't quote me on it.) They did that with me. I was rated PTSD with Major Depression. This avoids pyramiding, and pyramiding is big no-no in VA claims. Secondary conditions rated are not pyramiding. Here is similar information that reiterates Secondary-Connection towards the end. I hope this gives you an idea of how to go about building your claim. Best wishes. Getting the Most Out of VA Disability Claims Involving the Spine – Part 1 August 15, 2016/in Veterans /by Anne Linscott, Attorney Claims involving the spine, both the cervical spine and the thoracolumbar spine, are rated under the same general rating formula. The following spinal conditions are all rated under the same general rating formula: Lumbosacral or cervical strain (diagnostic code 5237): this would be the diagnostic code assigned to a veteran experiencing pain in their neck or back. Spinal stenosis (diagnostic code 5238): spinal stenosis is when the spaces in the spine are narrowed and cause pressure on the spinal cord and nerves. Frequently, spinal stenosis is present in the low back, but can be present in the cervical spine area as well. Spondylolisthesis or segmental instability (diagnostic code 5239): this is a condition that causes one bone in your back (a vertebra) to slide forward over the bone below it. This can result in the spinal cord or nerve roots being squeezed can cause back pain and numbness, or even weakness in one or both legs. Ankylosing spondylitis (diagnostic code 5240): this is a form of spinal arthritis that causes inflammation of the spinal joints and can result in severe, chronic pain. Ankylosing spondylitis can also cause inflammation, pain, and stiffness in the shoulders, hips, ribs, heels, and small joints of the hands and feet. Spinal fusion (diagnostic code 5241): Spinal fusion is a type of surgery that is performed to join two or more vertebrae together so that there is no movement between the two vertebrae. This surgery is often performed in individuals with spondylolisthesis and spinal stenosis. Vertebral fracture or dislocation (diagnostic code 5235): A vertebral fracture occurs when a vertebra becomes compressed due to trauma. Typically, a vertebral fracture results in symptoms such as limited spinal mobility, and standing/walking will make the pain worse while lying down on the back makes the pain better. A vertebral dislocation is when one of the small vertebrae in the neck is displaced following a traumatic injury to the head or neck. Symptoms of a vertebral dislocation include pain that spread into the shoulder and arms, tingling or numbness in the arm, muscle spasms in the neck, and weakness in the arms. The general rating formula that is used to rate the conditions listed above is mainly based on range of motion (ROM) measurements. The cervical spine (neck) and the thoracolumbar spine (low back) are rated according to the following criteria: Cervical Spine Thoracolumbar Spine 0% Flexion ≥45 degrees, OR combined ROM ≥ 340 degrees Flexion ≥ 90 degrees, OR combined ROM ≥ 240 degrees 10% Flexion between 30 and 45 degrees, OR combined ROM between 175 and 340 degrees Flexion between 60 and 90 degrees, OR combined ROM between 125 and 240 degrees 20% Flexion between 15 and 35 degrees, OR combined ROM ≤ 170 degrees Flexion between 30 and 65 degrees, OR combined ROM ≤ 120 degrees 30% Flexion ≤ 15 degrees, OR entire cervical spine is frozen in a favorable position Not applicable to thoracolumbar spine 40% Entire cervical spine is frozen in an unfavorable position Flexion ≤ 30 degrees, OR entire thoracolumbar spine is frozen in a favorable position 50% Not applicable to cervical spine Entire thoracolumbar spine is frozen in an unfavorable position 100% Entire spine is frozen in an unfavorable position Entire spine is frozen in an unfavorable position As you can see, ROM measurements play a huge role in rating spinal conditions. Because the rating formula is almost entirely based on ROM measurements it is important to make sure that a doctor performs ROM testing as accurately as possible. Also, the VA requires that all ROM measurements be taken with a goniometer. If a doctor doesn’t use a goniometer to measure your ROM, the VA will not consider the results. In addition to the ROM measurements, the general rating criteria for spinal conditions looks at whether the cervical and/or thoracolumbar spine is frozen in a favorable vs. unfavorable position. A favorable position means the ROM measurement for flexion or extension is 0 degrees. Unfavorable means any position that is not 0 degrees in flexion or extension. Conditions Secondary to Spinal Conditions Oftentimes, spinal conditions will cause other conditions that can be rated in their own right. For example, fractured and/or dislocated vertebrae can lead to pain and weakness in the arms, hips, shoulders, etc. People with spinal conditions also often change how they walk to compensate for the pain which can lead to knee and hip problems. Spinal conditions can also cause nerve problems. One of the most common conditions secondary to spinal conditions is radiculopathy. Radiculopathy is caused by compressed nerves in the spine and results in pain, numbness, tingling, or weakness along the nerve. If radiculopathy is caused by a low back condition, the symptoms will be felt in the lower extremities (thigh, calf, foot). If radiculopathy is caused by a neck condition, the symptoms will be felt in the shoulder and can travel down the arm and into the hand. If your spinal condition results in the development of a new disability or makes an existing disability worse, remember that you may be entitled to secondary service-connection for the new or aggravated disability. These secondary conditions would be rated separately from the underlying spinal condition.

Unless, you were diagnosed in-service with sleep apnea. It will be difficult to "direct-service" connect. But, if you know that you went to medical and it's documented you complained of sleep problems such as; waking up gasping for air, choking, severe daytime sleepiness,sleep study confirming sleep apnea in-service, cpap issued in-service etc.You may have a case for direct-service connection. Since you've been out of the service for awhile, the best route to take is "secondary connection". If you have a service-connected mental health, heart, respiratory,diabetes, neurological condition(TBI or other brain condition) Sleep Apnea is linked to those type of conditions. Here is what is required to secondary service connect: 1.Must have a service connected disability. 2. Current diagnosis of disability claimed 3. Dr.Nexus of opinion stating "at least as likely as not" #1 and #2 are linked plus a rationale. I claimed OSA as secondary to ptsd. I was granted OSA ten yrs after service.

I had a flat feet denial twice and both were denied on the premise that I had congenital flat feet. Which my entrance exam clearly shows I had normal archs in 1998. Then, 7 yrs later I was diagnosed with flat feet in-service. According to my research, I know I have acquired flat feet also known as flexible flat feet; not congenital. I know I'm at least 30% now. Severe: Flat foot is considered severe if there is obvious deformity (like pronation and abduction), significant pain, swelling, and calluses that are built up in abnormal areas. If only one foot has it, then it is rated 20%. If both feet have severe flat foot, then it is rated 30% total. Broncovet gave me some advice to: #1. Get it SC. #2. Then to the effective date from back in 2007. Using CUE. I was getting livid and I thought I could use CUE from the beginning. Not so fast doc25. ha ha. I asked Dr. Bash to help with the DBQ and a nexus of opinion for new and material evidence to re-open my claim. He's already reviewed all my medical evidence. I obtained the C&P exam from 2007 and there are discrepancies that I noticed right off the bat. The Physician Assistant DID NOT provide a rationale. It was merely speculation on the part of the examiner. At least, from my perspective. EntranceExam98.pdf C&Pfeetexampg1.pdf C&Pflatfeetpg2.pdf In-service Dx.pdf

§4.23 Attitude of rating officers. It is to be remembered that the majority of applicants are disabled persons who are seeking benefits of law to which they believe themselves entitled. In the exercise of his or her functions, rating officers must not allow their personal feelings to intrude; an antagonistic, critical, or even abusive attitude on the part of a claimant should not in any instance influence the officers in the handling of the case. Fairness and courtesy must at all times be shown to applicants by all employees whose duties bring them in contact, directly or indirectly, with the Department's claimants. It doesn't take a genius to figure ratings officers ARE NOT applying this statute. It seems like they disregard all and any probative evidence that would substantiate a veteran's claim. Any thoughts?

Just wait for the decision letter. If the date is wrong there also. File a NOD immeadiately. You can appeal the effective date. Have a VSO assist you or one of the other forum members that have more experience with appeals. Congrats on your granted decision.

If the C&P examiner does not concur with the other nexus and provides an unfavorable nexus? The favorable nexus provided, balances the evidence;in such cases, but the VBA seems to do what they want anyway. d. Handling Evidence in Equipoise As indicated at M21-1, Part III, Subpart iv, 5.1.k, resolve reasonable doubt in favor of the claimant if all procurable evidence, after being weighed, is found in approximate balance or equipoise. 38 CFR 3.102 dictates that the Veteran prevails when the evidence neither satisfactorily proves nor disproves an issue. Reference: For more information on applying reasonable doubt, see Alemany v. Brown, 9 Vet. App. 518 (1996).

I'd turn it in to the nearest RO, or VSO. I had another vet's disability claim letter mailed to my address. When I saw the 100% I was jumping for joy. Then I looked through it and whaddaya know? it wasn't mine. Wahhhhh! Went straight to the VSO two blocks away from where I live and turned into him to send to the other veteran. But, if you want to hold someone accountable, you probably should call the OIG. That'll put a big butt hurt on them. LOL.

Ok. I think at the Regional office and DRO level medical literature won't matter. But, on appeal to the BVA, medical literature relevant to the symptoms and condition(s) has helped some, not all veterans; in their case. You're absolutely correct about the nexus of opinion. It still must be in the evidence to meet all requirements of the caluza factors.

You're very welcome. Which Regional Office did this come from? They are completely disregarding your MOS. Appeal that mess. I concur with Buck to get another audiogram. Also, since you were denied, you'll need to request your C-file. If you have questions how to fill out the fax coversheet and the form, send me a message on here. Be sure to get assistance appealing. va3288.pdf 2017-01-18+Claims+Intake+Fax+Coversheet-1.pdf

Ok. So, the C&P examiner threw in a fancy sounding "NON-pathological tinnitus" phrase. Quack, Quack ducky. I call BS. Tinnitus is subjective, meaning only you can hear it. Objective Tinnitus, means when someone else can hear the ringing coming from your ears. Not very likely. So, provide the attached article I labeled "Tinnitus article" and educate the DRO. Yea. The audiogram is clear and unmistakable evidence that Tinnitus was documented in-service. Go to a VSO, DAV, or other veterans organization near you to assist you. It seems you have a copy of your service medical record already. If you do, here is how you'll want to gather your evidence: #1. Organize and start chronologically from the beginning with your entrance exam and entrance audiogram. You shouldn't have remarks about tinnitus in either. Then comb through for all of the patient notes that have complaints of ringing in your ears and make copies. Provide a copy of the above audiogram you posted on the forum last and be sure to circle, underline, put a sticky note with an arrow pointing to the Tinnitus remark. #2. You'll need to submit your rebuttle in your NOD. Assert the facts. Appeal to the DRO review. You were a flight crew member whom worked on the flight line. Cite the attached Tinnitus research study and include it in your evidence.(You are competent enough to have the sense to provide medical studies, articles, journal entries, that were done by medical professionals.) The General population is NOT exposed to the level of noise exposure that certain military occupational specialties are exposed to on a daily basis; such as Flight Crew, Artillery, Tank, Engine room personnel. #3. Ask friends, family, or co-workers for lay evidence giving their testimonial that you have complained and mentioned ringing in your ears that keeps coming back everyday for as long as they've known you. They have to use their own words, in other words, layman terms. Tinnitus is capped at 10%, but the longer they take with your claim you'll get a decent retropay. Tinnitus can get worse to the point that it can cause depression or anxiety on a secondary basis. A secondary-condition is rated seperate, usually. Which will increase your disability depending on the severity of symptoms of the depression or anxiety caused by tinnitus. It looks like you have some Hearing Loss. Did you put in a Hearing loss claim? If so, was it granted or denied? If not, it would be a good idea to submit one. I got 0% for Hearing Loss, I'll ask for an increase at some point when I go deaf enough. lol. I'm sure other forum members will chime in. Best wishes on your appeal. Tinnitus Research Study.pdf Tinnitus Article.pdf

QTC is the medical component of Lockheed Martin now. Why is Lockheed Martin in the business of Veterans Affairs?? Aren't they supposed to be a defense contractor? Although I work for the VA, I work on the VHA side. VBA is a totally different beast. https://www.triple-tree.com/investment-banking/transactions/qtc-acquired-by-lockheed-martin/ LHI apparently is part of UnitedHealthGroup. Isn't that an Insurance company? Corporate interests have made it a business to screw veterans and surviving dependents.

I have to correct myself. In a VA note dated 2-10-16, my pulmonologist documented: SLEEP LAB REVIEW AND MANAGEMENT NOTE Subjective: Sleep lab was available for review. Dr. jeffys supplied it. I have reviewed this sleep study which was performed on 4/27/2009 It was performed at Zerenity Sleep Center, Necessity for a cpap was demonstrated. The study demonstrated that abnormal respiratory events were abolished by 8 cm h2O pressure. Assessment: Sleep apnea severe enough to use CPAP

Thanks for sharing your info.

You're absolutely correct.Good to know. I was awarded October 23, 2017. I have a pulmonology appointment scheduled in a couple of months. I'll have my pulmonologist document that in my records. I appreciate the feedback. I'm also hearing the VBA has made changes to the PTSD criteria, but I have yet to find any literature on any recent changes.

My secondary OSA to PTSD C&P exam was absent of "medically necessary". I'm not suggesting you are wrong, "medically necessary" does provide the nexus of opinion added weight. My sleep study did state in the impression that; Sleep Apnea improved with CPAP. The DBQ, Nexus of opinion, and rationale met all the requirements for secondary-service connecting OSA.

Which service-connected disability are you going to use to secondary-service connect your OSA? TBI or PTSD? You can use TBI or PTSD, but you can't use both; if I'm not mistaken. Either way, you already meet 2 out of 3 requirements to secondary connect OSA. 1. Must have a service-connected disability 2. Must have a current diagnosis of disability claimed. 3. You're just missing the nexus of opinion. Which it sounds like you'll be able to obtain from the sleep specialist first for the OSA, as secondary to TBI. If you want to get an, IMO from the VA doc you'll need this article that was done by a VA doctor (see attached files), to give your request some teeth, along with the peer review journals you have to claim OSA, as secondary to PTSD; if you want to go that route. Best wishes on your claim. PTSD and Sleep Apnea article.pdf

Ok. There's a few questions I have for you. 1. Were you or the veteran diagnosed, in-service with OSA? If so, was a CPAP issued ? Was OSA claimed as a direct-service connection claim? 2. Were you or the veteran diagnosed, after-service with OSA? If so, is there currently a service-connected mental health condition, heart, neurological(brain), or respiratory condition and were issued a CPAP? Was OSA, claimed as secondary to any of those conditions? But, to answer your question. No, it does not fullfill the language requirement. I didn't have medication to control a sleep disorder, but I required the CPAP to sleep well and keep breathing during sleep, otherwise I'd stop breathing in my sleep. The ratings schedule is specific. To rate OSA at 50% the only requirement is a breathing assistance device such as a CPAP. I think this is a good opportunity to inform you that if a veteran was diagnosed with OSA after 1-year of discharge and service medical records are absent of complaints for breathing issues during sleep such as: very loud snoring, cessation of breathing during sleep, gasping to breathe. (Obesity does not always cause OSA, there's plenty of veterans and in the general population that are not obese that have OSA). Also, absent of an in-service sleep study and was never diagnosed with OSA in-service; will make it very difficult to direct-service connect. Secondary-Service connection is the probably the best route to take to service-connect OSA for an after-service diagnosis. As I previously mentioned, an SC mental-health condition, heart, neurological(brain), or respiratory conditions are known by the medical community to be co-morbid; meaning the simultaneous presence of two chronic diseases or conditions in a patient. I know this was alot of information, but I do hope it helps you out.

DBQs are meant to provide the C&P examiner and Ratings schedulers the medical evidence to give them a better picture of how your symptoms of each conditions are affecting you. The gathering of evidence phase takes approximately 1-3 months, but since you have multiple conditions, it "might" take a bit longer to go into the next phase as "Under Review" (the longer they take? your retroactive pay will be more for your claim, if it is granted.) I had a claim go from gathering of information to preparation for decision 1 and a half months, then it was sent back to gathering of evidence for another three weeks because the C&P examiner errored and opined the condition as direct-service connection. I had claimed a secondary connection disability. Unfortunately, my claimed was denied. But, I learned a few things. Since you have an ebenefits account. You can actually look up what the C&P examiner submitted, if it was a VA C&P examiner. If it was done by QTC or another contractor, they won't release those records to veterans. Bummer. In ebenefits, be sure to login on a personal computer or your cellphone: 1. Log in 2. Click on your Dashboard at the upper right of your screen. 3. Scroll down to where it asks,"What would you like to do next?" 4. Click on "Manage Your Health" 5. The next page will say "Manage Health Care Benefits" 6. Scroll down until you see "VA medical records". Click on it. 7. On the next page you'll see "VA Blue Button Report". Click on it. 8. The next page will read, "Download my Selected Data". On the date range you'll want to enter the start date the day before your C&P exam. Enter the end date on the day your C&P was scheduled for. 9. Scroll down a bit until you see, "VA Electronic Health Record History and Wellness Reminders". Click on the box that says "VA Notes".Scroll down further and click submit. 10. On the next page, you'll have your downloaded results. I recommend clicking on the "View" TXT it takes less time to load your information. I hope you received a favorable C&P exam. Best wishes.

I concur.

Hmmm...sounds sketchy to me. But, I'm usually paranoid. Do you have scheduler rated PTSD or other mental health condition? It might be one of those C&P exam to reduce a rating. Don't quote me on that. But IF it is to reduce ratings, they should've sent you a letter before the C&P. exam. If you go to the C&P exam and your ratings get reduced. Appeal because if they don't notify you first that's the Regional Office screw up. Be advised, I'm not trying to cause any unnecessary stress, my intention is just making you aware of what the VA "might" or "may" want to do. Here's some info for you to be prepared, in the event, this does occur. I really hope they don't try to screw with your disability. WHAT TO DO IF YOU GET NOTICE OF A POTENTIAL RATING REDUCTION VA is required to send a letter proposing the reduction of your benefits, if the decrease will affect the amount of monthly compensation you receive. The letter is not a final VA decision and so cannot be appealed, but VA gives you the opportunity to respond to the proposal by submitting evidence and/or attending a hearing. From the date of the letter, you have 60 days to submit evidence if you believe the reduction is not warranted. Within the first 30 days of the 60-day period, you have the option to request a hearing to be conducted by VA personnel unrelated to the proposed reduction. VA must consider evidence you submit during this period (including the transcript of the hearing, if you choose to attend one) and all previous evidence and medical records associated with your file. What are some types of evidence you might submit? You do not need to submit treatment records from your VA Medical Center as VA already has access to those documents. But it can be helpful to submit a medical opinion from an outside, independent doctor if your Compensation and Pension exam was not favorable. Additionally, you may want to submit statements from family, friends, or employers who have observed your ability to function in daily life and/or at work. If you choose not to submit evidence within the 60-day period, VA will issue a final decision reducing your rating. If, after 60 days or the review of your submitted evidence, VA sends a final decision that reduces your rating, you can file an appeal with a Notice of Disagreement form.

Yea, there appears to be an error on how bladder injury was rated. If I'm not mistaken, the ratings scheduler should have rated the higher of the two; being voiding dysfunction. HOW DOES VA DECIDE WHICH DIAGNOSTIC CODE THE SYMPTOM SHOULD BE CONSIDERED UNDER? By law, VA must choose whichever condition would most benefit the veteran. In other words, they must assign the symptom of concern to whichever condition will get the veteran the highest overall combined rating. So....the DRO did not follow the law on the issue of bladder injury. Boom! On the issue of GERD, under Code 7346 hiatal hernia, I still think your symptoms are rateable, at the very least, 30%.

I was under the impression it was BVA. My fault. Now that we know it was a DRO review. Move forward and appeal to the BVA. DAV or Veteran's lawyer will definitely help with that. I'm about 75% sure the BVA will provide due diligence to your case. 25% I leave it to the possibility that they may still get it wrong. If that happens take it to the Court of Appeals for Veterans Claims (CAVC ) If the CAVC still gets it wrong. Take it to the Supreme Court.

Congrats! Go to Ebenefits in your dashboard there will be a menu to the right. 1. Click on "Your Letters" Letter Generator. 2. Click on "Benefits Summary-Veterans Benefits" Towards the bottom of the letter you should see if you're P&T or not. If it's not there, give it a few days to update.