New Member With Questions About Reopening Claim (sorry, Long)

[sleepyjenn]

Hello, I've been a member for a while here, but I've never posted. I would really love some input from you all about the best way to go about reopening my claim with the VA. As of right now I am rated at 40% total, which breaks down to: 30% for Insomnia, 20% for cervical radiculopathy and strain with left upper extremity weakness, and 0% for mild left sacroiliitis. The 30% for Insomnia was based on a sleep study that showed disturbed nightime sleep. No MSLT (daytime sleep study) was done at that time. The 20% for cervical radiculopathy was for left shoulder pain that I had been seen continuously throughout my military service for, but had never gotten a firm diagnosis. Now, here is where I have questions.

Since being discharged in May 2005, my primary care doc (I am lucky that I am married to someone who is still active duty, so I still receive care in the base clinic) ordered an overnight sleep study with MSLT based on my continuing complaint of being constantly exhausted. Sleep issues/fatigue were well documented in my service records. The sleep study and MSLT found pathologic daytime sleepiness. My doc gave me the diagnosis of Idiopathic Hypersomnia. This is the first issue.

Second, doc ordered a cervical MRI to try and establish a firm diagnosis, based on the VA opinion that I have cervical radiculopathy. The MRI findings were:

Findings: There is a slight straightening of the normal cervical lordosis. The signal of the spinal cord is normal. There is no evidence of tonsillar herniation. All cervical vertebral bodies are normal in height and contour.

C2-C3 and C3-C4 show no significant disc bulge or disc herniation. The central canal and neural foramina are patent.

C4-C5 shows minimal disc/osteophyte complex posterocentrally. This is better visualized on the axial images. No significant central canal or neural foraminal narrowing is identified. There is left uncovertebral hypertrophy.

C5-C6 shows bilateral uncovertebral hypertrophy, which is more prominent on the left. There is superimposed bulge. No significant central canal or neural foraminal narrowing is seen.

C6-C7 and C7-T1 normal

Impression: Minimal Spondylitic disc disease of the cervical spine, predominantly at the level of C5-C6 and C4-C5.

My symptoms are neck/left shoulder/shoulder blade/left arm pain, numbness, tingling, burning. Weakness and shakes in the left arm at times. I am 28 years old, and these symptoms began when I was 23. It is well documented in my service records, just no diagnosis. I have an appointment with a neurologist in a week. This is issue #2.

Third, my primary care doc just diagnosed me with Rosacea. I have an appointment with a dermatologist on Monday.

Okay, the questions are: How do I go about submitting this information? One of the conditions is completely new (rosacea), but since I've been out for less than a year there will be a presumptive service connection, correct? When I go to the dermatologist and neurologist what information should I get from them to submit? Keep in mind these are not C&P exams, so the drs. will not be going by VA protocol. Do I ask them to write some sort of statement of their diagnosis? Any thoughts on what the heck my MRI findings mean? Has anyone had any experience with "spondylitic disc disease" (whatever that means--is that DDD, DJD, IDD, arthritis???), "Idiopathic Hypersomnia" or any similar sleep disorders, or "Rosacea?" If so, what ratings did you get or what ratings would you expect me to get? Increase of current rating, decrease? I think that's all my questions. Like there weren't enough of them, right? B)

Any who read/respond, thank you, thank you, thank you. I know I just wrote a lot of information to wade through but I wanted to try to give all the pertinent facts. If anyone needs more information to answer any of my questions, please let me know.

Thank you,

[sleepyjenn]

I did have a C&P exam back when they were first deciding my claim, but that's not where the MRI came from. At my C&P they only did an X-RAY and the doc poked around for a few minutes and had me do some movements (I guess to check for ROM). The VA came up with the radiculopathy diagnosis on their own. I was a little confused about this, too, so after I got my award and saw what they had diagnosed I went to my primary care doctor on base and told him. He ordered the MRI that I posted the results from here. I still don't have a complete idea what the implications of this MRI are. I guess I will find out when I go to the neurologist next week. I don't know about the herniation issue and the radiculopathy diagnosis...I just know what kind of pain I have. I can't say why the MRI does or doesn't explain the symptoms, except to say that maybe they need to look at the rest of my spine, too? I thought that maybe the osteophytes and the bulge at C5-C6 might explain the left sided pain, but I don't know enough about spinal problems to say that for sure. Are you confused because I don't have any herniations? I thought that's what a bulge was, more or less? Like I said, I'm pretty uneducated about spinal issues. I just know I hurt. B) Thanks for the advice!

[Guest fla_viking]

Dear Jenn

There is a one year presumptive periiod. Thats how I got my SC approved by taking psych tests within one year after service. However it took 22 years because the VA destroyed key evidence and would not allow a C&P examination.

You are very lucky to document all of this now. I would before the 1 year is up get all the tests you can to document your disablity. IF I were you I would even get blood work done because many times the illness can be documented but wont show up for years latter.

After all the tests I would ask the VA for a C&P. I would hand deliver to the examiner the main documents proving your disablity with a short statment telling the examiner what it all means.

Keep copys of everything to this day the VA makes me mail everyting twice because they dont get my mail. So much stuff is lost or destroyed by them that you may have to submitt copys of documents just to make sure they are looking at what you are looking at.

Terry Higgins

[sleepyjenn]

Terry, what kind of bloodwork are you suggesting? My primary care doc has done bloodwork for various things in the past, but are you thinking of something specific?

Thanks,

Jenn

[wallyg]

I did not say that Idiomatic Hypersomnia is a new condition; I said it was a new diagnosis. You need to differentiate between the two things. The VA personnel who handle your claim are NOT medically qualified, and are NOT supposed to make medical determinations. They are limited to associating the medical terminology that the Doctors supply, to their rating Manual. That means there are frequently mistakes made, as is apparently the case with your cervical radiculopathy.

The MRI results that you posted, do not suggest the possibility of any specific rating for the thoracolumbar spine, or the sacroiliac, which was why I made the comment about a 0% rating for the degenerative spinal condition. I would be curious as to the rationale behind their radiculopathy rating, as the MRI did not show anything likely to cause that.

If you actually have a cervical radiculopathy, it should show uo an an EMG/NCV, which I would expect the Neurologist to order, as that is the 'gold standard' test for such things as radiculopathy and neuropathy.

[john999]

Jenn

I agree with Terry. Get all the medical tests you think might involve a disability claim. After the one year period it gets very much harder to prove anything is service-connected. Even if it means going to your own doctors outside the VA get records of diagnosis and treatment.