Temporary 100% Increase

[MDanysh]

Hello everyone. Thanks in advance for whatever advice and words of wisdom you can offer. I don't know most of the acronyms or lingo, so forgive me if I get something wrong. I did search before posting, but didn't see our exact situation anywhere. Forgive me for the lengthy post, but I'm trying to include as much relevant info as I can.

My husband was in the Army from 1995-1997, when he was medically discharged. He was in an accident and suffered a severe compound fracture, and spent several months in the hospital going through several surgeries to repair his leg. He wound up with an intramedulliary rod with internal fixtures in his right tibia (a rod with screws, in case I didn't get the medical jargon right, lol). He was medically discharged and initially rated at 10% service connected disability. It was increased to 30% around 2002/3. Since then, he has had pain and swelling at the site of the break intermittently, but this past year, it increased to the point where the pain and swelling is almost constant and occurs every day. He was referred to the Orthopedic clinic at the Temple VA. The orthapedic surgeon there ordered x-rays, and when that didn't show anything, a bone scan was ordered at the end of April. The bone scan revealed new healing and growth at the site of the break from 1997. The surgeon didn't understand the reason for it, as there has been no recent trauma to the leg, and couldn't give a concrete reason for the continuous pain and swelling. So he decided that a rod (nail) and screw removal might relieve the pain and swelling. Surgery was scheduled for June 10, and the surgeon told him to expect to be home from work for most of the summer. Soon as we had all of the details, we started a claim for a temporary 100% increase evaluation on June 3rd. The surgery was a nightmare, btw (it looked like a butcher got a hold of his leg). Nonetheless, the surgery did take place. After four hours, the surgeon came to the waiting room and told me they were unable to remove the rod, and only took out one screw. As such, He released my husband to walk with full weight bearing on his leg the day of the surgery, but told him he could not return to work yet.

We returned to the Temple VA five days later for a post op follow up, and once again, the surgeon told him stay at home, no work, that they would follow up June 29. Went back June 29 for follow up and removal of surgical stitches. Dr told hubby they would discuss his being released to return to work in one month's time, pending pain levels, and to stay home and rest.

July 2nd, recieve response to VA claim, requesting evidence that he had had surgery and any other supporting evidence. We submitted the letter supporting claim, telling them everything I've just told you, as well as signing the release for his VA medical records. Mailed the same day. Then we waited. The wait was actually surprisingly short, even though it seemed to take forever. This past Thursday, we got the big envelope, with the letter dated July 16, informing us his claim was denied. The evidence they lised as using in their decision were his medical records from the Temple VA hospital, their letter requesting evidence, and my husbands initial claim form 21-0820, dated June 3, no mention of anything we sent in.

The following is word for word the reason for denying the claim:

"Entitlement to a temporary total evaluation because of treatment for a service-connected condition requiring convalescence:A temporary 100 percent evaluation may be assigned when it is established that a disability, subject to VA compensation, required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. Entitlement to this benefit is denied because treatment of the service-connected disability did not meet any of these requirements. VA Central Texas treatment records revealed you underwent hardware removal on your right knee on June 10, 2010. Two broken screws were removed, but the rod could not be removed. A treatment record also dated June 10, 2010 confirmed that Dr. xxxx cleared you to walk with full weight bearing on your right extremity on the same day as your surgery. The evidence of record does not show that you needed at least one month of convalescence, or had postoperative residuals, or treatment with immobilization by cast. Therefore, entitlement to a temporary evaluation based on surgery requiring convalescence is not established since the criteria were not met."

If he truly doesn't merit the temporary increase, that's fine, but I honestly don't understand this decision- he had the surgery, he's been home for going on 7 weeks now on Doctor's orders, he cannot return to work without his doctor's release, and the doctor won't sign a release. I would think that's the definition of convalescence. The decision letter went on to state that blah, blah, blah, you can submit additional evidence or appeal, or request a hearing if the evidence is something we haven't seen before and related to your claim.

Things are getting pretty desperate financially- we have 3 children (ages 12, 6, and 9 months), as of today, we're out of money, and will soon be out of food. Hubby returns to VA for another follow up on Thursday, and may or may not be released to go back to work- if he is, it will still be another 2 1/2 weeks before income starts coming back in. When we got the decision, we decided to try to apply for TANF, but did not qualify- for a family of 5, income has to be less than $268 per month, so we exceeded that with his current $497 monthly compensation. We tried food stamps, but don't qualify for expedited handling, because that same $497 exceeds our monthly utilities total by $3. They said they'd send us a letter, letting us know what they decide. I can't go looking for a job, yet, because if he's released to return to work Thursday, I'll have to quit after only a couple of days. We are in a lose-lose situation at the moment. (Sorry for the mini rant). I would have never waited it out if I thought the VA was going to out and out deny the claim- it never occurred to me that they would, because I thought the doctor ordering you to stay home for 6+ weeks qualified as convalescence.

Can anyone offer advice or an explanation? What would constitute new evidence? Is there anything we can do to reverse this decision?

[halos2]

Looks infected to me. Did they give him any antibiotics?? FWB not! No pain meds either, come on. Looks pretty cheap on the amount of sutures too. Is the area warm to touch? Drainage still? Color and odor to drainage. Warmth, redness, purulent drainage, odor = infection. Have you contacted the surgeon about the post op discharge orders? If the nurses are not willing to pass these on to you, check with the patient advocate tomorrow, for follow-up orders and procedures to follow. No therapy orders either huh?

[MDanysh]

Looks infected to me. Did they give him any antibiotics?? FWB not! No pain meds either, come on. Looks pretty cheap on the amount of sutures too. Is the area warm to touch? Drainage still? Color and odor to drainage. Warmth, redness, purulent drainage, odor = infection. Have you contacted the surgeon about the post op discharge orders? If the nurses are not willing to pass these on to you, check with the patient advocate tomorrow, for follow-up orders and procedures to follow. No therapy orders either huh?

He had the surgery 6/10, and These pics are from the first two days after the surgery. It was warm to the touch, but no odor, some seeping and bleeding when walking at the time- the surgeon was not concerned about it. Antibiotics? Nope. Discharge orders? They were "don't change the dressing and don't bath until after your post op follow up in 5 days." Therapy Orders? No. He was, however prescribed pain meds- 30 Vicodin with one refill. He takes one a day, when he can't stand the pain any longer and musters through (albiet in a pretty um,grumpy mood) the rest of the time.

Thank God the incisions have closed and he didn't wind up with an infection (unless it healed on it's own).

[Sgt Will Dove USMC]

You will need to get a letter from the Doctor, explaining the need to stay home for the last 7 weeks, and request an appeal to the VA. Take the letter you got from the VA Regional office with you to the VA, and have the doctor read it. You may have to get a little pushy with the doctor, and dont be afraid to ask for the Department Chief most likely the Chief of ORTHO in this case.

I have had some issues with the Docs here in Dallas, and I have found that the Hospital Administrator is a great tool to get them off their lazy rear end to write a letter. I had shoulder surgery, and had to stay home for over a month as well.

After you get the letter from the Doctor, you need to go to the VBA office in the hospital, and file the the appeal, and demand it be placed as a finiancal hardship. If you are out of money dont be afraid to prove it with a past due bill for the lights or water, or even have the landlord write a letter stating you are about to be evicted if the rent is not paid, and make sure there is a date.

Good luck

Hello everyone. Thanks in advance for whatever advice and words of wisdom you can offer. I don't know most of the acronyms or lingo, so forgive me if I get something wrong. I did search before posting, but didn't see our exact situation anywhere. Forgive me for the lengthy post, but I'm trying to include as much relevant info as I can.

My husband was in the Army from 1995-1997, when he was medically discharged. He was in an accident and suffered a severe compound fracture, and spent several months in the hospital going through several surgeries to repair his leg. He wound up with an intramedulliary rod with internal fixtures in his right tibia (a rod with screws, in case I didn't get the medical jargon right, lol). He was medically discharged and initially rated at 10% service connected disability. It was increased to 30% around 2002/3. Since then, he has had pain and swelling at the site of the break intermittently, but this past year, it increased to the point where the pain and swelling is almost constant and occurs every day. He was referred to the Orthopedic clinic at the Temple VA. The orthapedic surgeon there ordered x-rays, and when that didn't show anything, a bone scan was ordered at the end of April. The bone scan revealed new healing and growth at the site of the break from 1997. The surgeon didn't understand the reason for it, as there has been no recent trauma to the leg, and couldn't give a concrete reason for the continuous pain and swelling. So he decided that a rod (nail) and screw removal might relieve the pain and swelling. Surgery was scheduled for June 10, and the surgeon told him to expect to be home from work for most of the summer. Soon as we had all of the details, we started a claim for a temporary 100% increase evaluation on June 3rd. The surgery was a nightmare, btw (it looked like a butcher got a hold of his leg). Nonetheless, the surgery did take place. After four hours, the surgeon came to the waiting room and told me they were unable to remove the rod, and only took out one screw. As such, He released my husband to walk with full weight bearing on his leg the day of the surgery, but told him he could not return to work yet.

We returned to the Temple VA five days later for a post op follow up, and once again, the surgeon told him stay at home, no work, that they would follow up June 29. Went back June 29 for follow up and removal of surgical stitches. Dr told hubby they would discuss his being released to return to work in one month's time, pending pain levels, and to stay home and rest.

July 2nd, recieve response to VA claim, requesting evidence that he had had surgery and any other supporting evidence. We submitted the letter supporting claim, telling them everything I've just told you, as well as signing the release for his VA medical records. Mailed the same day. Then we waited. The wait was actually surprisingly short, even though it seemed to take forever. This past Thursday, we got the big envelope, with the letter dated July 16, informing us his claim was denied. The evidence they lised as using in their decision were his medical records from the Temple VA hospital, their letter requesting evidence, and my husbands initial claim form 21-0820, dated June 3, no mention of anything we sent in.

The following is word for word the reason for denying the claim:

"Entitlement to a temporary total evaluation because of treatment for a service-connected condition requiring convalescence:A temporary 100 percent evaluation may be assigned when it is established that a disability, subject to VA compensation, required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. Entitlement to this benefit is denied because treatment of the service-connected disability did not meet any of these requirements. VA Central Texas treatment records revealed you underwent hardware removal on your right knee on June 10, 2010. Two broken screws were removed, but the rod could not be removed. A treatment record also dated June 10, 2010 confirmed that Dr. xxxx cleared you to walk with full weight bearing on your right extremity on the same day as your surgery. The evidence of record does not show that you needed at least one month of convalescence, or had postoperative residuals, or treatment with immobilization by cast. Therefore, entitlement to a temporary evaluation based on surgery requiring convalescence is not established since the criteria were not met."

If he truly doesn't merit the temporary increase, that's fine, but I honestly don't understand this decision- he had the surgery, he's been home for going on 7 weeks now on Doctor's orders, he cannot return to work without his doctor's release, and the doctor won't sign a release. I would think that's the definition of convalescence. The decision letter went on to state that blah, blah, blah, you can submit additional evidence or appeal, or request a hearing if the evidence is something we haven't seen before and related to your claim.

Things are getting pretty desperate financially- we have 3 children (ages 12, 6, and 9 months), as of today, we're out of money, and will soon be out of food. Hubby returns to VA for another follow up on Thursday, and may or may not be released to go back to work- if he is, it will still be another 2 1/2 weeks before income starts coming back in. When we got the decision, we decided to try to apply for TANF, but did not qualify- for a family of 5, income has to be less than $268 per month, so we exceeded that with his current $497 monthly compensation. We tried food stamps, but don't qualify for expedited handling, because that same $497 exceeds our monthly utilities total by $3. They said they'd send us a letter, letting us know what they decide. I can't go looking for a job, yet, because if he's released to return to work Thursday, I'll have to quit after only a couple of days. We are in a lose-lose situation at the moment. (Sorry for the mini rant). I would have never waited it out if I thought the VA was going to out and out deny the claim- it never occurred to me that they would, because I thought the doctor ordering you to stay home for 6+ weeks qualified as convalescence.

Can anyone offer advice or an explanation? What would constitute new evidence? Is there anything we can do to reverse this decision?

[Sgt Will Dove USMC]

Almost forgot, if your hubby was housebound or bed ridden make the doctor put that in the letter as well. If this is the case you will get SMC as well. This applies if he was unable to care from himself like going to the restroom or showering without assistance.

[MDanysh]

UPDATE: He went for his follow up Thursday, was able to get the Doctor to write and print up the letter for him. That's the good news. The bad news is he has been released to return to work with restrictions= desk duty only. My husband is a heavy equipment operator and has been for going on 13 years. He works in coal mining, so his employer more than likely does not have a desk job he can do. Hubby was verbally told that he can no longer do any job requiring any sort of manual labor and that they made it worse by doing the surgery (good luck with us getting that in writing). We live in the country, and that's pretty much all there is. Even worse news- Ortho put him on a cane, told him there is nothing else the VA can do for his leg. He is being referred to a civilian trauma specialist and who knows how long that will take? We got the claim for temp 100% sent back in with the letter from doc, and also initiated a new claim for increased eval. So it's back to playing the waiting game. Seriously considering submitting claim for TDIU, for all the good it's probably going to do, seriously doubt that he'll get it, but what's the worst they can do? Say No? We've been hearing that already, so it won't be anything new.

BTW- We also got a copy of the Surgical report and notes, when they attached the tool to remove the rod from his leg, they broke it, with the bolt of the instrument still attached to the rod. They didn't have a tool handy that would remove the bolt, so they left it in the rod and sewed him back up with part of the tool still attached.

[Pete53]

You need a Lawyer and should file an 1151 claim and or a Tort Claim. Just my opinion. If you win an 1151 claim you will also get Service Connection. I hope that things work out for you and your family.