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brokensoldier244th
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Posts posted by brokensoldier244th
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I will follow up with that route. The 2nd response I received from the Dr, after he told me that I need to contact the appropriate person and I said that he was the appropriate person since he wrote the report, was
" The regional office is theappropriate channel not me. The federal govt will deem fit whether my exam isinsufficient. Then they will contact me. This is the exact chain of command"
So, I guess I get to talk to the VAMC. Thank you, Hoppy.
If it were me and the claim is denied I would contact the director of the hospital and tell them that you had a C&P exam and the examiner did not address the nexus issue one way or the other. Tell the director you feel that the exam was inadaquate and it should have addressed the nexus issue with full supporting logic justifying any determination. In the absence of the nexus the issue the exam is useless. Please investigate this examiner and provide me with an adaquate exam.
According to several SO's who I asked the question as to how to report C&P examiners I was told the C&P examiners work for the director of the hospital and to file complaints with the director of the hospital. A veteran who posted on hadit a couple years ago said this worked for him and he got a new C&P that was scheduled by the hospital.
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Well, that answers that. I emailed the C&P examiner, politely, at his office practice, figuring that if the VA assigned him to me for a C&P and I dished on myself for over an hour that that must constitute some form of patient/doctor relationship.
Apparently not. My request to have him clarify his findings to reflect whether or not my depression was or was not service connected was replied to with: "You need to contact the RegionalOffice to direct information that pertains to your claims. This is not myVA Account and is my personal office. Have a nice day."
Well, 1, you aren't a VA employee, so you may not HAVE a VA address, 2. I don't think I can contact the VA about an insufficient report until Im (possibly) denied anyway and Id really like to not have to appeal this, 3. you have a publicly listed fax, phone number at your practice that is freely available on the Web via a simple google search. I didnt think I was out of line, since I spent almost 2 hours in your 'office' for my C&P as a 'patient'. but hey, what the hell ever.
CAS
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Not usually until after October. It has to do with the consumer price index. Here is a thread you can get your head around, as it applies to us.
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If they had enough evidence to work it that fast, it's possible.
KIM that involving your congressionals, much like when i was on active duty and waiting for my MEB/PEB fiasco, usually slows things down rather than speeds things up.
CAS
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Im in decision phase as of today, so we'll see what happens.
My Axis(s) were listed as:
Axis I Diagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)
Diagnosis 2 (none)
Axis II Nothing listed
Axis III Medical diagnois-C&P records
Axis IV
Service related lumbar spine and sciatic nerve
GAF score 58
CAS
A veteran posted a report he got from a VA treating psychiatrist under another topic. The topic was "Berta and others". I copied and pasted his axis I diagnosis. This is what your psychologist can do for you. It involves making an accurate current diagnosis. Why she is balking at this is most likely a policy local to her department or hospital administrator. 2008-71 does not say a doctor does not need to make assessments that result in the most accurate diagnosis. The single episode can change to recurrent in your case because that is what the psychologist has been diagnosing you with.
I also saw a VA Psychiatrist – First Visit. He said
Axis I: Major Depressive Disorder, single episode, mild to moderate, likely related to
his Ulcerated Colitis.
Axis II: Deferred
Axis III: Ulcerated Colitis, hypertension, hyperglycemia
Axis IV: Moderate to severe
Axis V: GAF 60
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we'll see what he says, and go from there. At least I tried, and those who dare.......
CAS
It's more like irony than sarcasm. A person struggles to figure out what went wrong with the exam and how to resovle the problem and in the end the solution was simple. This is more an explanation of irony than a statement as to what I think will happen. Approaching doctors for an addendum is a coin flip. I have told veterans to do it and it worked and I have gone to appointments with them and it has worked. Unfortunately, it only works about 50% of the time.
The last veteran who I worked with that pulled this off told his psychiatrist that he had reported a mis diagnosis for a year and a half. He pointed out that he had a different diagnosis which was determined by psychometric testing and his psychologist had been reporting the right diagnosis the entire year and a half. The C&P examiner based a denial on the wrong diagnosis the psychiatrist had been reporting. The psychiatrist admitted the error and wrote an addendum changing the diagnosis. This resulted in the C&P going into the trash can. The doctors do not re write the entire report. They write an addendum. Sometimes the addendums get lost. You need to submit them with a statement in support of the claim and make sure they appear on the evidence listing.
To win my angioedema claim I had to get pushy. The raters were making up false evidence against the claim and ignoring slam dunk evidence in favor of the claim.
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Is that sarcasm? :-) Sorry, my sarcasometer is pegged this week.
As for whether I would trust an addendum right there, probably not-id feel like I was pressuring or threatening them, I guess.
Why didn't I think of that? I did try this with A VA staff clinician and got thrown out of his office. I tried it with another VA staff clinician who made a diagnosis of a less severe condition than what the treating reports stated. He typed up an ammendment while I waited. What would you do if the guy says "Oh dude I am so sorry. Why of course it is related to your back. I will type up an ammendment while you wait".
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I hope so. I had to appeal for the ED, and then turn around and appeal again for the SMC-k. Ick.
Brokensoldier,
Taking meds for ED is not a reason to deny ED. Do some reading. The meds are only a temporary solution for a chronic condition. Take away the meds and you still have ED. All the success on your appeal. You should prevail.
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nIce. I was approved for ED due to nerve impingement in my back, but the never inferred SMC-K, despite being prescribed levitra. I had to file a separate claim for it-which they then denied because I have kids. *WTF* I had to appeal, and so I wait. Congratulations!
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296.23 in DSM IV = Severe without psychotic features
Maybe he meant that....but.......here we are again with the ambiguous C&P
*sigh* Thanks for bearing with me on this Hoppy. I typed up almost all the C&P. Ill comb through it again, but nothing jumped right out at me that said "A=B or A/=B". He was a contracted Psychologist that normally does troubled teens in a secure facility, but you'd think that he would know what he was supposed to do. My treating doctor has listed me in here SOAP notes as "Major depression, Moderate, Recurrent" every time we've met since May, if that helps. Hopefully I don't come across as stalkerish or weird, but I found his practice and I faxed him today with my concerns about there not being a yea/nay statement. We'll see what he says, if anything.
Attached is what I faxed him. I hope it doesn't sound stalkerish, or that im not breaking some cardinal rule. I assumed since he saw me for my exam that I could contact him as a patient.
To clarify, I do not feel the C&P exam presented any significant evidence against your claim. The problem is that the nexus question is the question that is formated to include "more likely than not", "as likely as not" and less likely than not" related to your back condition. The C&P examiner did not offer an opinion. The single episode of depression can be totally unrelated to the recurrent depression your treating doctor is talking about. The code the C&P examiner used is not even a DSM IV code. 296.23 ICD refers to the international classification of diseases (ICD). The VA is required to use the DSM IV when adjudicating a claim. What you need is a diagnosis of a psychiatric condition due to or secondary to a service connected medical condition. I can not tell your treating doctor she has to make a diagnosis. However, I have in fact had VA clinicians make such a diagnosis without even asking for it. A proper and full diagnosis would be beneficial. It is still possible the raters will be forced to throw out the C&P because he used the ICD code. Then the notes from the treating clinician without a specific diagnosis of a psychiatric condition due to the service connected condition would require that the raters connect some dots. I do not count on raters connecting the dots. Like John said, get the doctors to put in the report exactally what will make it clear to the raters your condition is.
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im still in development right now. DAV guy says he has it to a rater, but that was just the other day. My treatment thus far has been ongoing for 5 months, but I was injured in 2001 and discharged in 2002 for a trauma (lower back/fall/injury) and im currently rated at 40% for that, and 10% for extremity radiculopathy. I really like my therapist and she and I talked yesterday about her providing a prognosis/duration statement but she swears by the directive and said she talked to her supervisor as well to get an idea of her boundaries. Are raters required to look for the 'magic words' of "is likely, is as likely as not," etc, or can they address the record as a whole? She has noted that I am seeing her for pain, as does the C&P guy, but they don't say it with the phrase du jour. Being that im in Development/rating right now, im in the worst possible time to be worrying about this, and I don't see her again until the 7th (about every 3-4 weeks). im just worried that there isn't enough to go on, that the disparity between the Examiners diagnosis of "single occurrence" vs her diagnosis of "recurrent" will reflect badly in some way on me. Does "single occurrence (296.23 ICD) mean something different than I would interpret it to mean?
Thank you for your explanation of things.
CAS,
This is a continuation of my previous post.
This is the long version of the issues involved in your claim. The first thing I want to point out is that I have discussed this type of claim with several VA staff psychologists including the Chief of Psychiatry at a VAMC.
My training includes; formal training in psychology at a major university, advanced training on how to develop Workman's Compensation claims at the American Institute of Specialized Studies and instruction from an MD/JD that all injuries have resultant secondary comorbid psychological symptoms that the claimant most be screened for. These secondary psychological symptoms can resolve over time. Sometimes they do not resolve. In any event before the doctors I worked with signed off a claim this issue was addressed. I am amazed that the VA does not routinely screen injured veterans for secondary psychological considerations and require that they be addressed on all claims. I guess the difference is that the doctors I worked with under labor law were truly advocates for the injured worker.
The fact that your claim has advanced to the decision phase without this issue being specifically identified and addressed with supporting logic in favor of or against service connection is an aberration to someone with my training. The fastest way to deal with this is to get a medical opinion from either a VA treating clinician or a private clinician. In either case they must meet the requirement the VA has for mental health examiners. Appealing on the basis that the C&P was inadequate could delay the claim for years. However, making such an appeal as soon as possible is recommended in the event they have some way of fast tracking a new exam. A veteran who posted on hadit claimed he brought up the issue of an inadequate exam with the director of the VAMC and received a new exam in a very short period of time. I would recommend talking to your treating clinicians, filing an appeal and talking to the director of the VAMC. When advancing a claim, surrounding the VA is the best way to keep your claim from falling through the cracks in the system.
Back to the VA staff clinicians. This is what I was taught by the VA psychologists. When evaluating secondary psychological symptoms due to medical conditions the level of psychological symptoms must be considered an "overreaction". Over reactions are identified by behavior patterns that are the product of excessive "guarding". For instance, an individual with a lower back problem is released by the treating medical doctor and the individual refuses to seek work because they are afraid that they will re-injure their back. This psychological reaction can be short term or long term. The length of this type of reaction is hard to predict.
Different clinicians will throw different diagnoses at these individuals. Depression and anxiety disorders are very common. It is my experience that VA clinicians will use depression and anxiety disorders. This is what occurred in the BVA case that I sent you in which the veteran was awarded service connection for a psychological condition due to their back injury. Even in view of VHA directive 2008-71, I see nothing prohibiting a treating VA clinician from making a diagnosis of an anxiety disorder or mood disorder due a medical condition or secondary to a medical condition if it is the most accurate diagnosis of your condition and providing supporting logic justifying the diagnosis. I have obtained this type of report from VA treating clinicians for other veterans.
If your treatment records show that you are depressed due to your pain, I am not sure this would result in a separate "overreaction". Everybody is depressed by pain. However, if your treatment records show that there are specific behaviors that are considered "overreactions" and these behaviors result in a long period of decreased social or occupational function, then a psychological diagnosis would be appropriate. I have not found a specific time requirement for a secondary psychological condition. However, I would argue it would be the same as required by the DSM IV for a diagnosis of an anxiety or mood disorder without a comorbid medical condition. Having this spelled out in the treatment records would benefit your claim. However, I have seen C&P examiners simply make the diagnosis without any supporting logic and the claim was awarded. This is especially true when the C&P examiner is a VA staff clinician who the VBA has been seeking opinions from for many years.
Some veterans have told me they benefited by having their treating clinicians read my letters.
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If the VA heath providers are not supposed to opine on whether or not your depression (in this case) is a direct result of your SC issues, and the C&P examiners don't either, but the raters are looking for 'that statement', then what? Seems to be a sort of catch-22.
CAS
CAS
Read the directive carefully. It says they can comment on prognosis and degree of current disability. It says nothing about etiology or cause. You are seeking an opinion as to the cause of the depression. VA doctors are not required to address cause for the purpose of resolving a veteran's claim. The directive tells the doctor to refer the veteran to proper channels. The proper channel's according to the VBA is the C&P process.
I have tried to turn this around and asked the doctor if it would be beneficial for treatment to know the cause of the veteran's depression. I get different answers to this question. I was told by one VA doctor that it does not matter for treatment to know the cause. The treatment is the same no matter what the cause. I am not sure this would be true in your case and if you are told this you should seek a second opinion from a qualified treating clinician. Due to the complications with VHA directive 2008-71 you might need to go outside the VA to get this resolved. Considering the opinion that was used in favor of the veteran's claim I posted the link to, you should be able to get a similar opinion.
I take the BVA case to a clinician and tell them I need a report similar to the one that the BVA used to award the claim. As you can see from the case I linked this can get real complicated and drug out. The veteran in that case had to obtain opinions to rebut the C&P exam.
<BR clear=all> Eking an opinion
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Good on you. That's awesome. Im sorry that you have to consider an appeal, but for the time being you've at least got 50%.
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There is a court case called the "Deluca" case that empowers VA C&P personnel to regard pain during repetitive motion as part of their examination, but nothing that addresses physical pain. Chronic pain can also be ruled as a mental health issue, but not both as a physical and mental issues.
CAS
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Interesting reading. Thanks for that.
I just called her and left a VM with that directive listed and I read the fun parts to the machine. Hopefully she will write up something. Id have to go look through all my treatment notes, but Im pretty sure my initial set of them she notes that Im there for depressions, pain and service connected lower back. In the first meeting notes under the diagnosis she notes that I will continue to come see her to address my depression and pain. i know that isn't a nexus, but I was hope for preponderance of evidence.
*shrug*
Thanks for looking at it a bit, Hoppy.
CAS
It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23)
My Axis(s) were listed as:
Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)<BR style="mso-special-character: line-break"><BR style="mso-special-character: line-break">
C&P examiners are experts at killing claims. It appears to me this examiner did everything possible to kill your claim. In researching your claim I wound up reading a current post you put on another website. After reading what you posted recently on hadit I see no connection between your depression and the service connected pain condition. The C&P is silent for a nexus between pain and depression. Correct me if I am wrong on this. If there is no link it would be a stretch for the rater to award the claim.
GO TO THIS LINK AND READ THIS DECISION
http://www.va.gov/vetapp11/Files1/1103562.txt
You will need a report similar to the one used to win the claim I told you to read at the BVA. Also, it appears your treating psychologist deferred making a link between your depression and service connected pain. This is a VA induced cop-out. She is following VHA directive 2008-71 ( see paragraph "D" below". She is qualified to say yes or no, there is a link. However, the VHA told her she only needs to make statements addressing you current ability to function.
d. Medical Statements to Support VA Benefits Claims. When honoring requests for medical statements by veterans for VA claims adjudication, care must be taken to avoid conflict of interest or ambiguity.
(1) Determination of causality and disability ratings for VA benefits is exclusively a function of the Veterans Benefits Administration (VBA). VHA providers often do not have access to military medical records, and may not be familiar with all the health issues specific to military service, such as environmental exposure. As a result, they may not feel comfortable in stating causality of a current condition. However, this does not preclude VHA providers from recording any observations on the current medical status of the veteran found in the medical record,
including their current functional status. All pertinent medical records must be available for review by VBA. NOTE: VHA continues to provide compensation and pension (C&P) examinations and reports as requested by VBA, as part of any new disability claims or review process.
(2) Requests by a veteran for assistance in completing a VA disability claim are to be referred to VBA through official channels; however, the clinician, if requested by the veteran, must place a descriptive statement in the veteran's medical record regarding the current status of the veteran's existing medical condition, disease, or injury, including prognosis and degree of function. This may then be requested by VBA for the purposes of making a claim determination
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Its hard to tell, you know? The 30 and 50 percent ratings are similar in many ways, and the definitions of 'reduced reliability and productivity', 'disturbances of motivation and mood', and 'impairment of short and long term memory' could be construed any number of ways. He didn't ask about work absences or work directly, more about how I interacted at work. Maybe I should have taken in my write up for absences but since he didn't ask about it I didn't think of it. My treatment notes indicate instances where i have yelled at my kids for no reason, punched a hole in the wall while dragging their bed out of their room (since they wouldn't clean under it), snapped at people, and other such things. I would hope that those notes would be included as well.
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I got my MH C&P notes back today, and as I peruse them I don't see too much that is glaringly off until I get to the "Symptoms" section in Section II, Clinical notes. Under the list of symptoms, only Depressed Mood is marked [X]. Nothing about disturbances of motivation or mood, disturbances of sleep, mild memory loss-things that are in my treatment notes with my Psychologist. Under the "Occupational Social Impairment" section he checked: "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation".
Tossing and turning, mind-mapping to keep thing straight, and my lack of motivation for social settings is noted in the write up under "current mental health", though. I just hope that stuff typed out in block gets read, too, and not just the things that are 'X'd off.
It also bothers me a bit that the diagnosis code is "MDD, Severe, Single Episode" (296.23) when my normal treatment notes from early April to present designate it as recurrent. How does a rater take that and run with it?
Is it normal for there to only have 1 thing marked in that entire symptoms section, even though the instructions state to check any and all symptoms related to the diagnosis? The rating isn't just based off of the checklist, is it? They will look at my psych notes,etc as well, where these things are noted? I thought the C&P was to take that into account in their overall write up, summarizing it, if you will, but maybe not. Is there going to be any weirdness with having only a single GAF when my clinician uses SOAP style notes with no GAF scores? (thus, no pattern)
My Axis(s) were listed as:
Axis IDiagnosis-Major Depresive Disorder, Moderate, with Obsessive Compulsive tendencies (not full blown disorder)ICD Code 296.23 (Major Depressive Disorder, Severe, single episode)
Diagnosis 2 (none)
Axis II Nothing listed
Axis III Medical diagnois-C&P records
Axis IV
Service related lumbar spine and sciatic nerve
GAF score 58
"There is no history of mental health hospitalization. The veteran was started on Sertraline by the physician initially for PME and then over time he started taking that daily for his mood, 1/2 tab daily"
"The veteran is married, 4 children. The veterans wife is employed as asst. manager of a movie theater. The veteran noted that often times they watch DVR or rental movies for family activity. The veteran noted that usually after the new movies have been out a few weeks they are more likely to do to movies when there will be less of a crowd."The veteran noted that his children are involved in [activities] and that he is involved, his wife does the majority of those activities."
"The veteran noted that Sertraline has calming effect upon his emotions and thought process. The veteran noted that he has been trying to work on physical prowess by exercising but that Physical Therapy said he was working too hard and in a manner that would not be conducive to reduction in pain. The veteran has avoided narcotic pain medication as he does not want to further dull his faculties. the veteran does not that there are times where he does not have an appetite and forgets to eat. The veterans energy level has been low to poor. The veteran noted that he will "mind map" to keep his clientele straight. The veteran has difficulty getting comfortable at night. The veteran tosses and turns repeatedly during the night. The veteran noted that he tends to be regimented and structured so as to try to contain the depressive symptomology.
The veteran noted that hsi sex drive is "not really...we cuddle, we dont' have sex......I take drugs for it, but then I don't 'want to'....". The veteran does not feel hopeless-he says that is why he sees his psychologist. the veteran does have some time he feels helpless. The veteran knows that his back pain "is going to be a lifetime thing. I get sick of it...i get tired of it hurting...i get tired of people asking why I don't spend time with them or do things with them... because there are days i can't get off the couch."
The veteran has friends "and we do things sometimes, my close friends understand most of the time. Acquaintances feel like I am a buzz kill". The veteran is not suicidal nor homicidal. Th vetera's mood is depressed daily nearly every day or all day, he describes difficult concentrating at home and at work."
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I thought only combat vets could collect both?
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Its down pretty much every weekend when they update. I doubt it has anything to do with D.C.
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maybe they changed their memo post policy.
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mine memo posted this morning. You're probably okay.
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Government GS wage ratings are public information-the VA is a government agency.
http://www.payscale.com/research/US/Employer=The_Veterans_Administration_(United_States)/Salary and many other places as well.
CAS
And you know this HOW?? Amazing broncovet how much you know about the VA system??????????
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IF you read the comments, one of them says that the system in place for recording granted leave ultimately depends on the timeclock administrator (not that unusual, my software company does it the same way), so when your leave time is approved by your supervisor, you assume that you can go-thats the system in place. If it is not recorded you end up long or short. The same thing happened at my company and we only have 20 employees. The girl that was supposed to do it spent more time checking myspace than doing her job, so a few months after she was fired a periodic check was done of the paper time keeping records vs. the computer before the new person started. Same thing. It was a mess, but we are small enough that it was forgiven, since it wasn't our fault that our leave was approved by her and she never recorded it.
It happens a lot, which is why we went with a fingerprint sign in time clock that doesn't rely on paper, and downloads our leave balances from our parent company every year when they update.
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I filed an appeal a month ago, with a pretty vitriolic letter. My DAV guy appealed by saying "This veteran appeals...." and that's it. I cited chapter and verse (and regs) that I was ED, service connected, and on medication for it, so therefore I shouldn't have to appeal something officially that, according to the reg, should have been inferred and granted as soon as I won my ED appeal.
CAS
Brokensoldier244th, Have you heard anything, have you received your letter (We are still processing your application for COMPENSATION.) Call,Call, and keep calling!
Mh C&p In, Some Questions About Symptoms Noted Vs. Progress Notes
in VA Disability Claims Research
Posted
Should I wait to complain, since my claim is in decision, or should I wait and pursue it after?
CAS