Question About Approprietness To Reason And Basis For Denial Of Claim

[Rockhound]

When I received my denile of my claim for secondary issues that were caused and/or the result of my SC issues.

I'll try to do my best in esplaining the problem as I see it.

I finally got and increase of 10% for a Nasal Fracture and Deviated Septum due to trauma, while hospitalized for a unrelated mental condition, another story, another time.

I then applied for secondary issues as a result of the nasal fracture and deviated septum on the primouse that the structural changes that resulted from the fracture and deviated septum is cuasing Non-Allergic and/or Allergic Rhinitis like symptoms, and/or symptoms similiar to those of Chronic Sinisitus.

They denied my claim stating that my SC Nasal Fracture and Deviated Septum is less than likely the cause for the diagnosis of Allergic Rhinitis and their is no supporting literature to prove otherwise.

I've tried to make it clear to them that I am not claiming that the SC issues is the cause of a disease process. I'm trying to show that the symtomology or symptoms, although similiar in nature to the different types of Rhinitis and/or Sinisitis is caused by the abnormal air flow due to the acquired abnormal structural changes as a direct result of the nasal fracture and deviated septom, for which I have found supporting literature to prove out my claim. I also have on at least two occasions been told I have an additional problem with the collaps of the nasal wall upon labered breathing through the nose, which was as likely as not the result of the same trauma and/or procedure used to reduce the fractured nasal bone shortly after the trauma occured.

I need to know or given some direction on how to precent this obvious error in their assumption of what the claim is actully about or the proper reason and basis of the claim

Rockhound Rider B)

[Wings]

x

x

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Sounds like you need a NEXUS from an M.D. ~Wings

PS. Good to see you around, Rockhound. I was gettin' worried about you!

[sixthscents]

If it isn't listed in the table of diagnostic codes.........then you are, essentially, out-of-luck, for you will be holding forth on a theory of disease that there is no "code" for, hence there is no way that they can realistically "rate" it. And, you can bet yer bottom dollar that they aren't going to create one, just for you.

Sorry, but, that's the way I see it.

Larry they are a rated conditon..

6510 Sinusitis, pansinusitis, chronic.

6511 Sinusitis, ethmoid, chronic.

6512 Sinusitis, frontal, chronic.

6513 Sinusitis, maxillary, chronic.

6514 Sinusitis, sphenoid, chronic.

General Rating Formula for Sinusitis (DC's 6510 through

6514):

Following radical surgery with chronic osteomyelitis, 50

or; near constant sinusitis characterized by

headaches, pain and tenderness of affected sinus, and

purulent discharge or crusting after repeated

surgeries.............................................

Three or more incapacitating episodes per year of 30

sinusitis requiring prolonged (lasting four to six

weeks) antibiotic treatment, or; more than six non-

incapacitating episodes per year of sinusitis

characterized by headaches, pain, and purulent

discharge or crusting.................................

One or two incapacitating episodes per year of 10

sinusitis requiring prolonged (lasting four to six

weeks) antibiotic treatment, or; three to six non-

incapacitating episodes per year of sinusitis

characterized by headaches, pain, and purulent

discharge or crusting.................................

Detected by X-ray only................................. 0

Note: An incapacitating episode of sinusitis means one that

requires bed rest and treatment by a physician

I understand exactly what you are trying to do, and it is a justifiable claim. You are saying that the service connected injuries have caused symptoms similar in aspect to sinusitis, and Rhinitis.

Now this is also important...

The Respiratory System

Sec. 4.96 Special provisions regarding evaluation of respiratory

conditions.

(a) Rating coexisting respiratory conditions. Ratings under

diagnostic codes 6600 through 6817 and 6822 through 6847 will not be

combined with each other. Where there is lung or pleural involvement,

ratings under diagnostic codes 6819 and 6820 will not be combined with

each other or with diagnostic codes 6600 through 6817 or 6822 through

6847. A single rating will be assigned under the diagnostic code which

reflects the predominant disability with elevation to the next higher

evaluation where the severity of the overall disability warrants such

elevation. However, in cases protected by the provisions of Pub. L. 90-

493, the graduated ratings of 50 and 30 percent for inactive

tuberculosis will not be elevated.

So I take this to mean that even if you get a rating for sinusitis or Rhinitis, you can only get ONE, and that one be elevated due to symptoms...

So, I would file the claim for sinusitis, but insist that it be raised due to the rhinitis symptoms. I would state that the Sinusitis is due to the service connected injury, and like Wings said, get an IMO stating that the deviated septum is and has caused these symptoms...

Thats the way I would go.

Bob

[Rockhound]

sixthscents and others, this is the criteria that I am claiming. My diagnosed chronic sinusitis, consistantly reported in my AXIS III list, is discribed upon examination that meets the 10% for non-incapacitating episodes. I'm asking for no less or no more than what I am elligible for and can show by my records. Rhinitis is rated similiar weather it is of a non-allergic or allergic type. 10% is well within the scope of the rating for my simptoms and should be rated thusly.

Wing: thanks for your concern, this past month or so has been hard on me, I've had to increase my psych and depression meds to their maximum and it has left me quite the zombie and I haven't been able to function very well, plus my ability to schedule tasks has pretty much been shut down and I was having trouble remembering to do things or things I had already done, which even involved my meds. By mid day I had pretty much forgotten what I did that morning and so on and so on. I was getting really freaked out that it was one of those time where I would have been better off if I had checked my self into the hospital until I could get things under control once again. I'm doing better but not having the ability to remember things and do things when I should have, I am coming into this winter behind on my budget for my heating budget, so it's going to be a bit cold for awhile so I can make my heating fuel last longer without letting my water pipes freeze up and break.

Tammi, my not so little kitten has taken to laying in my lap more when I sit and watch TV and is staying curld up to me in bed, even under the covers, until I fall asleep, then she will move to the foot of my bed. She even acts like an alarm clock in the morning when it is time to feed her, her allowance of canned cat food. she gets right up in my face and pats my on the nose until I wake up. sound like of silly but its true. she's been my nurse maid through this whole ordeal. I wish I had more pets like her, but I can't afford to feed any more than Tom and her. I'm afraid Tom my other and much older cat hasn't forgiven me for getting Tammi, I think. He tolerates her at best and spends most of his time outside. I've tried to keep him inside but he pust up such a fuss, I'm afraid he will either hurt himself while trying to find a way to get outside. He even fusses when I pick him up, he does scrath or bite by he kind of grawls and hisses at me to let me know he is annoyed.

It's late and I guess I have taken up enough time and space socializing about my and my problems, but I do have to figure out what to do next on my claim. I fear they are doing this just so I will get so frusted and quit, which I don't plan to do, and if I do, I am going to claim CUE for not rating my claim under the right criteria. but then I would have to first get them to reconsider the claim if they say it is past the year or date in which I would have to reopen with new and material evidence, when in fact the claim still remains open because they haven't decided the claim for whch I had submitted for.

Rockhound Rider B)