Need Help Understanding The Note In Schedule Of Ratings

[carlie]

This is from the Rating Decision:

The results of the exam show your mandible was normal.

X-ray of the maxilla showed evidence of pins used in your reconstructive surgery.

Arthritis was not shown. There was incomplete healing of the soft tissue in the right maxillary vestibule and scar tissue was evident. Your ramus and palates were normal.

Your temporomandibular articulation showed your

Inter-incisal range of motion was between 31 and 40 mm.

Your range of right and left excursion was between 0 to 4 mm.

The physician diagnosed incomplete healed right maxillary fracture.

An evaluation of 10 percent is assigned from October 1, 2007.

An evaluation of 10 percent is granted, whenever there is indication of

limited inter-incisal movement between 31 and 40 mm,

or lateral excursion between 0 and 4 mm.

Your evaluation is based upon temporomandibular and lateral excursion reduced ranges of motion.

A higher evaluation of 20 percent is not warranted because the evidence

Does not show inter-incisal movement between 21 and 30 mm

§ 4.150 Schedule of ratings—dental and oral conditions.

9905 Temporomandibular articulation, limited motion of:

Inter-incisal range:

0 to 10 mm 40

11 to 20 mm 30

21 to 30 mm 20

31 to 40 mm 10

Range of lateral excursion:

0 to 4 mm 10

Note—Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion

My question:

In reading the NOTE part above shouldn’t the veteran be compensated for both?

10 percent for limited inter-incisal movement between 31 and 40 mm,

AND

10 percent for lateral excursion between 0 and 4 mm.

I feel that the decision maker has combined the evidence of

limited inter-incisal movement and limited lateral excursion

together - thus only allowing for one ten percent evaluation.

The decision maker has stated in the rating decision,

"An evaluation of 10 percent is granted, whenever there is indication of

limited inter-incisal movement between 31 and 40 mm,

or lateral excursion between 0 and 4 mm."

I do not understand the Schedule to be saying that the rating is

limited to either one OR the other.

Thanks for your help, guidance and opinions.

carlie

[LarryJ]

Larry,

I read your post on DC 9916 and I feel he would do best

in sticking with the DC that VA has already rated under

(9905).

If VA were to change the DC to 9916 I feel he would only

be rated as Moderate displacement ................................. 10.

Do you still agree that under 9905 his evidence would warrany

two - 10 percent ratings ?

carlie

no no no, I was, in my own sneaky way, suggesting that the 9916 in ADDITION to the 9905, a seperate claim, for the non-union of the maxilla, which was diagnosed apparently during the C&P which established the 9905 but was not formulated into a claim, hey, it's another 10%, right?

[rentalguy1]

I'm gonna stick my neck out on this one. I disagree. The note is telling the rater to NOT combine the two ratings. Nowhere does it say that a rating should be assigned to each. The CFR would call that pyramiding. It would be the same as having a broken tibia and a broken fibia. They would only assign a rating consistent with the higher of the two evaluations (one would hope).

Anyway, that's the way I'm reading it.

[carlie]

Larry,

You are right on with that 9916 - my guess is VA would either grant it

or deny under pyramiding.

An issue that has really pissed me off with this vet's claim is that

he was denied any additional dental treatment because he's been out over 90 days.

The VA had done some surgery to correct an infection left in his mandible

from the surgery that DOD had done. Since VA told him he wasn't SC'd for dental treatment

purposes he has been paying a private dentist for dental services to include

making a mold for his TMJ - so far he's paid out about 3K on this.

He also has quite a bit of tissue missing since VA had to cut out all of the infection left fom

the surgery DOD had done.

I really feel he should push for some dental care for treatment purposes.

carlie

[LarryJ]

Okay, so granted the two ranges of motion, since they are both listed under the same diagnostic code, regardless of the note instructing that the two not be combined, could lead sensible people to two differing conclusions as to what the VA actually Intended to say, and some will reach the conclusion that, no, only 10% can be granted and others to say, no, they intended for the two to be rated seperately (and only G-d is privy to the "right" answer B) ).

But, either one of these conclusions notwithstanding, I do feel that the non-union of the Maxilla, as it is under a totally different diagnostic code, and is or is not inexplicably tied to the ROM issue, should be filed upon as a different claim, for it is a medical issue that could lead, if it hasn't already, to different problems, none of which has to do with the ROM issue at hand (osteomylitis comes to mind). And, those "other" issues should be pointed out in the original claim concerning the 9916, to thwart the VA from even raising the issue of "pyramiding".

or sumptin' lak dat.............

[broncovet]

Carlie...

I agree with you. When the "Note" says they "shall not be combined", this means that they are rated Seperately, that is, 10% for lateral, and another 10% inter-incisal.

Lateral means side to side movement, where "inter-incisal" would mean horizontal movement within the incisor.

Since your jaw bone also has TWO sides, my thinking is that there would also be a BILATERAL factor. JMHO.

[LarryJ]

Carlie...

I agree with you. When the "Note" says they "shall not be combined", this means that they are rated Seperately, that is, 10% for lateral, and another 10% inter-incisal.

Lateral means side to side movement, where "inter-incisal" would mean horizontal movement within the incisor.

Since your jaw bone also has TWO sides, my thinking is that there would also be a BILATERAL factor. JMHO.

BILATERAL. Now why didn't I think of that!

This is gettin' to be FUN!