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Mcafee

C+p Exam

Question

Hello All Hope All Is Well.

My Question is during all of my C+P Exams I have never seen or reviewed my C-File for this exam and yet the examiner always states that it was present.

Anyone else expierence this process?

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M21-1-1MR

7. Requesting a Medical Opinion or Examination

Introduction This topic contains information on requesting a medical opinion or examination to develop claims, including

• VA's responsibility to provide medical examinations or obtain medical opinions for the claimant

• when to request a medical opinion or examination

• when to request a medical opinion versus an examination

• stating requests clearly

• what the opinion request needs to contain, and

• the importance of identifying evidence relevant to the request.

a. VA's Responsibility In claims for disability compensation, assist the claimant by providing a medical opinion or examination when the opinion or examination is necessary to make a decision on the claim.

b. When to Request a Medical Opinion or examination A medical opinion or examination may be necessary when, after the development of all other relevant evidence, including the statement of the claimant, the file

• contains competent medical evidence that the claimant has a current disability, or

• contains competent evidence that the claimant has persistent or recurrent symptoms of disability

Note: A claimant is competent to describe symptoms of disability that he/she is experiencing, such as pain in the knee. However, because a claimant ordinarily lacks medical training and experience he/she would not be competent to diagnose his/her own medical condition or offer a medical opinion.

• contains supporting evidence from service records or other sources that the claimant suffered an event(s), injury, or disease in service that may be associated with the claimant's current disability or symptoms of disability, and

• does not contain sufficient medical evidence to make a decision on the claim.

c. When to Request a Medical Opinion versus an Examination A medical opinion versus an examination should be requested when only the following is necessary to decide the claim:

• Reconciliation of different diagnoses

• Opinion concerning the relationship between two conditions

• Opinion about functional impairment

• Etiology and nexus opinions

• Allen v. Brown cases (e.g., when the issue is whether a service-connected condition has aggravated a non-service connected condition)

• Independent medical opinions

• Opinion regarding the extent to which service-connected disabilities affect the veteran's ability to perform physical and non-physical tasks in order for VA to determine whether the veteran is unemployable.

Note: Many opinion requests require information that would be gleaned as part of the normal examination process which the physician should not be precluded from conducting, if necessary.

d. Stating Requests Clearly When seeking a medical opinion

• be very clear about what information or opinion is being requested

• send the following to the medical examiner:

• the claims folder, and

• the opinion request

and

• direct the medical examiner to

• review it, and

• provide a rationale for any opinion.

e. What the Medical Opinion Request Must Contain The medical opinion request should clearly state the nature of what is needed. The requester must clearly indicate if he/she

• wants an opinion on the etiology of the condition

• requires the physician to reconcile differing opinions, or

• wants any other medical opinion.

It is not adequate to merely refer the examiner to the claims folder containing Board of Veterans' Appeals (BVA) remand instructions. However, there is no prohibition from quoting the BVA instructions as long as the instructions are clear about whether a medical opinion is required.

f. Importance of Identifying Evidence The requester should identify the available evidence to assist the physician in focusing his/her review. The evidence should be tagged in the claims folder, but the examiner must be advised that he/she is not limited to reviewing only this evidence.

Note: Avoid the potential problem of steering the examiner to review only the evidence pre-selected as relevant since a medical professional may have a differing opinion as to what evidence is relevant and must not be limited in the record review.

The identification of the evidence must include a general description of it, indicating the

• source

• approximate dates, and

• subject matter.

Edited by allan

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Had A C&P exam for PN last Nov. Didn't see my C file and didn't ask. Got a copy of the exam report and was suprised to see the following. C-FILE REVIEW : Not requested by VARO.

The examiner did review my medical records. She also reviewed 21 pages of medical records from my pvt neurologist (I took a copy just in case ). She scanned his records into my VA records and said they should have been there since I had given them to my PCP and submitted them with my claim.

She also used his findings in her report. thank God for a Vet friendly Doc.

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Allan - Thanks for doing the legal research and posting it for us.

John - Thanks for letting us know that your C&P examiner not only reviewed your records but also scanned them into your VA records. I agree, a vet friendly doctor is a blessing.

Thanks,

TS

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My last C&P exam fell on "Black Friday" ( the day after Thanksgiving ) The fng doctor with less than two years of experience, treated me like I was an annoyance and the scowl on her young face showed her disapproval of having to work on a long Holiday weekend. Though I did not see my file during the 20 min. exam, I did notice her slouch out of her office with a massive volume of one of my files with her, as well as a look of disgust on her face.

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I know VARO physically sent my file to the VAMC where the C&P exams were done. But my file is some 5" or 6" thick and I sure as heck didn't see anything like that present in the room in either of my last two exams. It is possible they reviewed it prior to the exams. My medical records were available on the computer. They stated repeatedly that the records were reviewed

But...

The exam reports were so horribly falsified there's no telling if they bothered to read it or not. I was able to rebut many of their statements with nearly 30 pages from my file. (I did have a recent copy) I mean they stated I did not have any special shoe inserts when I wore them to the exams and the authority for their custom fitting was in my VA med records. They said I had no unusual shoe wear when the shoes I wore were so worn and there were photos of three such pairs of shoes in my C file. They said my gait was steady and even in the same report they described my gait as being antalgic. Even so, my med records have a statement that I had "Trendelenberg Lurch." The report said my X-ray report did not indicate hallas valgus when the report did in fact say there was...

The list goes on and on...

Did they bother to read my file? Perhaps. They sure denied a lot of things my file said I claimed were wrong. Moreso than can be accounted for by chance. They knew specifically what to address.

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