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lumbosacral Spine - Secondary Conditions
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ken1939
I am: 10% SC for degenerative disease, cervical spine; 10% degenerative disease, lumbar spine amd 10% tinnitus. I am appealing the ratings for the spine conditions and am asking for additional benefits for secondary conditions i.e. headaches and lower extremity pain. The secondary conditions have already been denied and I will appeal that decision as soon as my other appeal has cleared.
How do I know what codes the VA used when rating my case? There is no mention of codes in the decision documentation other than a reference to title 38. I read a lot in the forums about trying to get a case rated under certain codes. How, for example, can I present my case for the secondary nerve pain for the lower extremities? On the one hand, I have a report from the VA neurologist examiner where he does not give an actual diagnosis but opines that the pain is secondary to my SC lumbar condition. The claim was denied on the basis of no diagnosis. On the other hand, I do have a diagnosis from another VA examiner, an orthopedic surgeon, who says: " The veteran has lumbar degenerative disk disease, spondylosis, and spondylolisthesis with partial left foot drop. there is additional functional loss due to pain and weakness after repetitive use. The major impact is from the pain. There is additional functional loss of 5 degrees due to pain after repetitive use X 3. The straight leg raising causes low back pain on the left at 70 degrees. It is at least as likely as not that the nerve pain in the lower extremity is secondary to the lumbar spine condition." This examination was done 2 days before the neurologist's examination but was not included as evidence when deciding this case.
I also have an examination report from a private neurologist that I have not submitted yet. He says: " The study (his examination) shows electrophysiologic evidence consistent with a left L5 radiculopathy." He goes on to say " the MRI scan of the lumbosacral spine shows anterolisthesis of L5 on S1 with moderate bilateral L5 neural foraminal narrowing as well as degenerative disk disease elsewhere."
I will include the Dr. reports along with my summary when I submit my appeal. I have been studying the forum and the table of codes but for the life of me I cannot see a way to guide them to the right codes. The more I read the more I become bogged down with information overload. Thank you.
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