Opinion On Reopen Claim Letter

[ruby]

Re: Reopen Claim

I am requesting to reopen my claim for reactive arthritis (ReA) in all joints secondary to cyst (rated as scar 0% sc).

As evidenced by the following it is my belief the ReA was the direct cause of an infected recurring cyst that developed while on active duty.

In support of my claim I have included copies of pertinent service medical records and veteran medical records along with letters from those with knowledge of these frequent recurring cyst.

18 Dec 1975: 1 in tender node R med thigh hard.

19 Dec 1975: c/o of swollen lymph node in inner aspect of L thigh leg x yesterday-very painful- states she applied hot soaks to leg last PM with no relief

I was leaving the base for leave on 20 Dec 1975, I was instructed to stop at any hospital should it become necessary for me to seek further medical attention for this infected cyst. The military facility refused to do anything further due to my leave.

I was forced to stop and have the cyst lanced upon arriving in Tampa, I was to sick to drive to my home, I parked at a doctors office and waited for him. He lanced the cyst and instructed me to keep hot towels on it for it to continue to stay open and drain, he also started me on antibiotics. Within a few days later I developed a rash and I went to MacDill AFB, for medical attention.

Undated note - This occurred within a week of December 20, 1975. MacDill Hospital. Infected sub cysts groin -no treatment ordered (saw private md couple of days before)-rash Scabies probably acquired in boot camp.

25 Jan 76 Staph infection-was treated by civilian doctor for staph infection (subcutaneous cyst in groin area without success pt c/o discomfort and fatigue.

26 Jan 1976: Staph and Scabies

From January 1976 until Nov 1978, I used hot packs to treat any further cyst that occurred during this time.

Nov 22 1978 at1035 am (2 mos post discharge from USMC) Fever 2-3 days large swollen area near perineum and top of L thigh:

22 Nov 1978 at 6:40 pm additional note due to allergic reaction- DX acute lymphadenitis infection

Nov 29 78- Pt returns for follow up of cellulitis- resolution of celluitis (a cyst deleveoped and resolved during this time period).

5/21/84: Cyst medial infected R thigh.

During a Comp Exam dated 5-1- 85 it was noted; cyst was still present 2-3mm very small.

During all my encounters with the medical professionals regarding this matter, whether they realized it or not they always made me feel like I was dirty and unclean. I primarily didn’t seek medical attention for this problem, since they never did anything for them I applied hot soaks and attempted to get them to open. After I became a registered nurse with 20 years of critical care experience I felt comfortable lancing them using aseptic technique. As a registered nurse, I was able to obtain antibiotics from a physician if the need arose.

There were frequent times that I was unable to accept work when I was working agency due to a severe flare up with numerous foul smelling cyst both in my groin and axillar.

On xxx I informed my primary xxxx ARNP that I had been avoiding seeing the GYN physician due to frequent cyst and blackheads in my perinum/ groin area.

On December 28, 2007, I was questioned by my rheumatoligst Dr.xxx, Chief of Rheumatology if I ever had any cyst in my groin area or under my arms. At that time I was having a severe flare up as noted in his notes.

At that time Dr xxxx, Chief of Rheumatology reviewed portions of my service medical records and in his opinion the 0% SC for this cyst has been missed diagnosed and the correct diagnosis is hidradenitis suppurtiva and the reactive arthritis is secondary to this condition.

On January 15, 2007, Dr. xxxx, Chief of Rheumatology again reviewed a portion of my medical records relating to these cyst and stated a second time "57 yr old WF with reactive arthritis secondary to hydradinitis suppurtiva.

Enclosed are additional statements from close friends and family that are aware of the continuous problem I have had related to the frequent and recurring cyst.

I hereby certify that th information I have given is true to thebest of my knowledge, memory and belief.

Suggestion anyone, if not I sending it.

[Ricky]

ruby - does your rating decision state cyst - rated as scar or does it say scar, claimed as cyst. There should be some language somewhere in there that will provide an answer.

If you are claiming a secondary condition to a cyst in your new claim, then it appears to me that you have never been service connected for a cyst based upon how I read your post.

I think rental is on the right track in that this should SC you for the proper primary condition and will then allow the secondary condition. However, it will not lead to a decision for a reopened claim on the scar and I think that you will have a hard time if you try to get an effective date as the same date of the rating for the scar. Just my opinion. This is based upon my reading of your post which really does not lead me to believe that your are connected for a cyst. Most ratings for a Scar end up at the 0 percent level unless they are painful to the touch and Scars definitely do not lead to joint problems. Now most that are rated for a scar are usually rated for the disease/injury that caused the scar if it has not or can not be corrected by medical treatment. So you really need to determine if you are rated for the cyst.

Edited January 25, 2008 by Ricky

[rentalguy1]

Ricky...I think she is actually rated for a cyst, but it falls under a scar's diagnostic code, because that most closely proximates the disability in the absence of a exact diagnostic code in 38 CFR 4. That is, if I'm reading the posts correctly. That's why I steered her in the direction that I did.

Ruby...if you can pull out your original decision letter and post up what is says, verbatem, we can tell you if we've set you on the correct path here.

[ruby]

I am SC for cyst 0% rated as a scar.

Here's what a BVA wrote in 1986

New skin growths, benign, will be rated as scars. Superficial scars which are poorly nourished with repeated ulcerations or which are tender and painful on objective demostation will be rated at 10 percent. Other scars will be rated on limitation of function of the part affected.

Here's the decision 1986

A cyst of the right thigh, not more than 2-3 mm in diamater, recurred in 1984 the cyst is not currently infected or otherwise shown to be symptomatic.--Increase was denied.

My medical records both in service and va show that I was treated for an infected cyst/celluitis of the r thigh (groin) 4-5 times. Then I stopped going to the va and treated them myself.

What I wanted to do was to bypass asking for a correct dx that will slow everything up--I wanted to ask for secondary due to cyst. Reactive Arthritis is caused by an infection. Simpliest dot connection here.

I want to avoid getting denied due to 3.307--chronic within 1 yr ratable at 10%.

If they had known what I had or I saw someone who knew while in the service or va then I would have gotten the 10%.

If I go with the correct dx, then I will have to show that the first cyst was the beginning of the HD---since this apparently isn't a well know disease process, I don't want to get a examiner that is an idiot and I have to appeal.

[rentalguy1]

Good, this is exactly what I thought was going on. If you don't want to attempt to get the correct dx code, then just omit the portions where I mentioned it below. THe only problem i am seeing with this, is that the cyst is going to have to be infected at the time of the new C&P in order to get an increase. I think you have enough medical evidence that shows past infections which would cause the ReA. But you will definately need the signed nexus forms from the doctor to get anywhere with this. Without that form, they will most likely deny from the getgo. Good luck!

[ruby]

rentalguy,

I think I have enough scarring to show they are frequent in nature and I have several that are present, right now I am on antibiotics, so they are not inflammed.

Is bypassing the correct dx the best way to approach this. I have some BVA decisions that are favorable on this issue.

What I have is a statement from the doctor saying hidradenitis is the probably cause of the ReA-now that I am reading his exact words. It doesn't say cyst, here is exact words

She has radiographic sacroilitis bilaterally. Now she reports hidradenitis in groin for 30 yrs. Now she has axillary pustules as well.

After reading this verbatim-he is saying I said I had HD-which isn't correct

Next note says: 57 WF with reactive arthritis secondary to hidrandenitis

ImP as above pt is competely permanently physically disabled. He has put this in his last 3 notes.

In his last letter I wrote, he read and I did take my records for him to review says:

Hidradenitis Supportiva is a know cause of RA and this condition more likely than not is contributing factor to her ReA. I have reviewed her smr dated-then the dates

Again another statement completely physical permanently disabled.

I guess I have no option but to go for a change in DX.

[rentalguy1]

I personally would (and am in the process of) getting the dx code corrected on my ratings. You will need the nexus statement, spelling it out exactly, from this doctor to make this happen. his nexus letter needs to say that "It is more likely than not that the patient's service connected cyst caused her hidrandenitis which started shortly thereafter the diagnosis of the cyst. Furthermore, since hidrandenitis is a known causative factor for ReA, it is at least as likely as not that the veteran's ReA is secondary to her hidrandenitis, which was most likely caused by her service connected cyst." Or at least something very close to this effect. Good luck!