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Reconsideration For Tbi

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ironsoldier77

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I have been seeing the TBI clinic at my va hospital for a few years now. I had previously put in a claim for mild TBI. I had multiple contact with blasts in Iraq. 2 Combat tours with 1st AD Infantry. I also have a PTSD rating of 50% and Tinnitus at 10%, total 60%. I have been unemployed since 2008 and I went through voc rehab and they found me infeasable for work,untrainable,not expected to get gainful employment. I have gone through Neuropsych testing and here is the diagnosis from that testing. I am hoping this will help me get atleast 10% so I can get TDIU. I have already put in a claim for increase on my PTSD rating,mild TBI and TDIU all at the same time. Just did this on wednesday.

CONCLUSIONS AND RECOMMENDATDIONS: Mr. Anderson is a 32 year old,White,married and unemployed when the last testing session was completed. His work ihistory does not reflect stable emplyment. He was referred for a cognitive evaluation by his primary care provider after complaining of difficulty in concentrating and meory problems. He has an unremarkable academic history with a high school graduation and one semester of college. HIs family of origin was stable:however his father died just before he left for Iraq. H has a stable relationship history in his only marriage of eight years. He has three years of credible service in the the army with two combat tours to Iraq. He reports being stunned from multiple blast in juries while serving in Iraq. He has no history of substance abuse , or legal problems. His social life is limited to family due to anxiety associated with being in crowds and other symptoms of PTSD. He generally functions idependently and attends to his activities of daily living.His premorbid level of verbal intellectual functioning was estimated to be high average. Current intellectual functioning was in the average reage. All IQ scores were in the average range except for working memory which was low average. He has mild impairment in concentration and focusing on information in the auditory channel. Mild impairment in concentrating and focusing could contribute to the mild loss of intellectual functioning reflected in the drop from high average to average intelligence. Memory functioning was avearage to low average. Auditory memory, visual working memory and immediate memory were lower than expected for his intellectual functioning. Visual memory was intact despite mild difficulty in focusing and concentrating on visual channel information. He has had significant losses of memory abilities. His observed behavior, history and the test data are consistent with the following diagnoses:

Axis I-Mild Cognitive Impairment likely associated with Blast Injuries

Posttraumatic Stress Disorder

Depression (ICD-9-CM 311./300.4)

Insomnia (ICD-9-CM 780.52)

Tobacco use disorder

Axis II-NONE

Axis III-Brain diseases due to trauma (ICD-9-CM 3)

Acute pharyngitis

Low back pain

Knee: arthralgia

Tobacco use disorder

Axis IV-Exposure to combat and loss of job

Axis V- GAF=55, mild to moderate impairment

Medical problems that could contribute to cognitive impairment include brain disease and pain. PTSD, depression and insomnia could also contribute to impaired concentration. Hearing impairment could contribute to auditory memory problems and a hearing examination may be warranted. HIs past history of having tubes in his ears as a child could have contributed to a failure to develop auditory memory abilities. Medications that could contribute to cognitive impairment include clonazepam, but this is usually seen in much older patients. Mr. Anderson may benefit from medications that target concentration like those used in the treatment to attention deficit disorder,and an evaluation for a trial of one of these medications is recommended. Unfortunately the prognosis for PTSD with mild traumatic brain injury is worse than the prognosis for PTSD without brain injury. Most of the treatments for PTSD involve learning new strategies for managing the symptoms of PTSD, and when learning is impaired, progress in treatment may be slowed. Continued treatment for depression, insomnia and PTSD is recommended. He is also being seen in the speech pathology for cognitive rehabilitation and this should be continued until maximum benefit is achieved. With the recent loss of his employment, a vocational rehabilitation referral may be warranted, depending upon his progress in the PTSD outpatient treatment program.

So, thats the report from the doctor that did the psych testing. When I read this it almost sounds like a "slam dunk" and that I might get awarded a SC for mild TBI. I really hope it does, because it would make me eligable for TDIU, which is what I really need. I was also wondering if its possible that the VA could go ahead and award 100% P & T instead of just TDIU?

I am on full SSD benefits as well and that along with my VA benefits at 60% is all i have to live by. We barely have enough to keep our house. I am almost at the point to where my life just seems meaningless and I really hope I get the TDIU, mild TBI and increase for my PTSD. Im having a hard time gettng an increase for my PTSD. It seems that i have to be some deranged lunatic, murder someone or get locked up. to be even considered for an increase. I dont know what to say when I go to the C&P exams for PTSD increases.

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Trying to get the TBI SC atleast 10% so I will meet the first criteria for tdiu. Which should be granted with the evidence I have.

iron,

I am wondering if the VA will say they can't grant SC to you for TBI

at a 10 percent level as supported by medical evidence (from VAMC or private) neurology that states

you have significant memory loss even under DC 8045 - TBI

I believe the VA just might come back and say this would be pyramiding.

Because you are currently service connected and receive 50 percent compensation

for DC 9411 - Post Traumatic Stress Disorder - due to memory loss, a claim for the same benefit

under a second diagnostic code can not be allowed as this would be pyramiding.

Please see the criteria below.

DC 9411 - PTSD

Occupational and social impairment with reduced 50 reliability and productivity due to such symptomsas: flattened affect; circumstantial,circumlocutory, or stereotyped speech; panicattacks more than once a week; difficulty inunderstanding complex commands; impairment ofshort- and long-term memory (e.g., retention ofonly highly learned material, forgetting tocomplete tasks); impaired judgment; impairedabstract thinking; disturbances of motivation andmood; difficulty in establishing and maintainingeffective work and social relationships...........

I for sure could be 100 percent wrong - but that's where my mind is at tonighton this one.

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I dont know if you saw this or not, but this is the TBI physicians notes/results from the psych testing. Does this help at all in my claim??

CONCLUSIONS AND RECOMMENDATDIONS: Mr. Anderson is a 32 year old,White,married and unemployed when the last testing session was completed. His work ihistory does not reflect stable emplyment. He was referred for a cognitive evaluation by his primary care provider after complaining of difficulty in concentrating and meory problems. He has an unremarkable academic history with a high school graduation and one semester of college. HIs family of origin was stable:however his father died just before he left for Iraq. H has a stable relationship history in his only marriage of eight years. He has three years of credible service in the the army with two combat tours to Iraq. He reports being stunned from multiple blast in juries while serving in Iraq. He has no history of substance abuse , or legal problems. His social life is limited to family due to anxiety associated with being in crowds and other symptoms of PTSD. He generally functions idependently and attends to his activities of daily living.His premorbid level of verbal intellectual functioning was estimated to be high average. Current intellectual functioning was in the average reage. All IQ scores were in the average range except for working memory which was low average. He has mild impairment in concentration and focusing on information in the auditory channel. Mild impairment in concentrating and focusing could contribute to the mild loss of intellectual functioning reflected in the drop from high average to average intelligence. Memory functioning was avearage to low average. Auditory memory, visual working memory and immediate memory were lower than expected for his intellectual functioning. Visual memory was intact despite mild difficulty in focusing and concentrating on visual channel information. He has had significant losses of memory abilities. His observed behavior, history and the test data are consistent with the following diagnoses:

Axis I-Mild Cognitive Impairment likely associated with Blast Injuries

Posttraumatic Stress Disorder

Depression (ICD-9-CM 311./300.4)

Insomnia (ICD-9-CM 780.52)

Tobacco use disorder

Axis II-NONE

Axis III-Brain diseases due to trauma (ICD-9-CM 3)

Acute pharyngitis

Low back pain

Knee: arthralgia

Tobacco use disorder

Axis IV-Exposure to combat and loss of job

Axis V- GAF=55, mild to moderate impairment

Medical problems that could contribute to cognitive impairment include brain disease and pain. PTSD, depression and insomnia could also contribute to impaired concentration. Hearing impairment could contribute to auditory memory problems and a hearing examination may be warranted. HIs past history of having tubes in his ears as a child could have contributed to a failure to develop auditory memory abilities. Medications that could contribute to cognitive impairment include clonazepam, but this is usually seen in much older patients. Mr. Anderson may benefit from medications that target concentration like those used in the treatment to attention deficit disorder,and an evaluation for a trial of one of these medications is recommended. Unfortunately the prognosis for PTSD with mild traumatic brain injury is worse than the prognosis for PTSD without brain injury. Most of the treatments for PTSD involve learning new strategies for managing the symptoms of PTSD, and when learning is impaired, progress in treatment may be slowed. Continued treatment for depression, insomnia and PTSD is recommended. He is also being seen in the speech pathology for cognitive rehabilitation and this should be continued until maximum benefit is achieved. With the recent loss of his employment, a vocational rehabilitation referral may be warranted, depending upon his progress in the PTSD outpatient treatment program.

iron,

I am wondering if the VA will say they can't grant SC to you for TBI

at a 10 percent level as supported by medical evidence (from VAMC or private) neurology that states

you have significant memory loss even under DC 8045 - TBI

I believe the VA just might come back and say this would be pyramiding.

Because you are currently service connected and receive 50 percent compensation

for DC 9411 - Post Traumatic Stress Disorder - due to memory loss, a claim for the same benefit

under a second diagnostic code can not be allowed as this would be pyramiding.

Please see the criteria below.

DC 9411 - PTSD

Occupational and social impairment with reduced 50 reliability and productivity due to such symptomsas: flattened affect; circumstantial,circumlocutory, or stereotyped speech; panicattacks more than once a week; difficulty inunderstanding complex commands; impairment ofshort- and long-term memory (e.g., retention ofonly highly learned material, forgetting tocomplete tasks); impaired judgment; impairedabstract thinking; disturbances of motivation andmood; difficulty in establishing and maintainingeffective work and social relationships...........

I for sure could be 100 percent wrong - but that's where my mind is at tonighton this one.

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What do you mean by PTSD-due to memory loss??

I am so confused at this point. I though I had a simple case here with the evidence from the TBI doctor, vocrehab, and my mental health provider(psycologist).

After reading what you posted I have became so depressed. Even though you say you could be wrong. I felt good about everything I submitted, now I wonder if im wasting my time. You say they might consider it "pyramiding". OK, if thats the case, could they increase my PTSD to 60%?? Obvisoulsy i have some mild TBI according to the neuropsych testing. He calls it mild cognitive impairment. My memory is not messed up because of PTSD! The PTSD is just making the TBI worse. Thats what the doctor is trying to say in his report I think?? Im sorry if im not making any sense. But what you posted to me doesn't make any sense either. I read a link you posted on the evaluation of TBI. WOW! I couldnt make sense of any of it!! I had to keep re-reading everything and it just made me even more confused. I really do hope your wrong and they can award me something for TBI, because I do have it, even if just mild. And if they can't, I feel they should increase my PTSD if they think PTSD is the cause of my cognitive impairment, which it isnt! I feel like im rambling on and repeating myself here. I will stop here and wait for a response.

Berta!!!! If you out there, I would really love your thoughts on this too! Thank you everyone for taking the time to respond to my thoughts and feelings. Its really helpfull, even if its not something I dont like to hear.

iron,

I am wondering if the VA will say they can't grant SC to you for TBI

at a 10 percent level as supported by medical evidence (from VAMC or private) neurology that states

you have significant memory loss even under DC 8045 - TBI

I believe the VA just might come back and say this would be pyramiding.

Because you are currently service connected and receive 50 percent compensation

for DC 9411 - Post Traumatic Stress Disorder - due to memory loss, a claim for the same benefit

under a second diagnostic code can not be allowed as this would be pyramiding.

Please see the criteria below.

DC 9411 - PTSD

Occupational and social impairment with reduced 50 reliability and productivity due to such symptomsas: flattened affect; circumstantial,circumlocutory, or stereotyped speech; panicattacks more than once a week; difficulty inunderstanding complex commands; impairment ofshort- and long-term memory (e.g., retention ofonly highly learned material, forgetting tocomplete tasks); impaired judgment; impairedabstract thinking; disturbances of motivation andmood; difficulty in establishing and maintainingeffective work and social relationships...........

I for sure could be 100 percent wrong - but that's where my mind is at tonighton this one.

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iron,

I don't mean,"What do you mean by PTSD-due to memory loss?? "

It's the other way around, memory loss due to PTSD and not TBI -

that is what the examiner stated that helped shoot down your claim for TBI.

In the information you've just posted, I can see medical evidence that the

doctor has fully supported with full medical rationale, that should help enable your

claim for TBI to be granted.

What I was trying to get across was my opinion that,

being you are already compensated for your memory loss by way of receiving 50 % for your PTSD.

I feel the VBA would say that compensating you for memory loss twice,

( 1 way by comping PTSD at 50 % and 2nd by comping for memory loss due toTBI )

would be pyramiding.

You posted, " My memory is not messed up because of PTSD! "

In your NOD that you posted you state,

"The examiner provided an opinion that my memory impairment was not related my TBI

but was related to the mental disability."

The probability is - in reality that your memory loss is co-morbid with PTSD and TBI.

Next - PTSD doesn't even comp at 60 %.

All mental disorders (except eating disorders) comp at - 10 - 30 - 50 - 70 - or 100 %.

I think the best thing you can do regarding your claim/appeal for TBI is to look over the medical criteria for

DC 8045 - TBI and compare the symptoms and findings shown in your new medical evidence (from the TBI Clinic/Neurologist) with the 8045 criteria.

Maybe I'm off base, I too have TBI and PTSD and my memory can get screwed up too : )

Here's the 8045 criteria :

8045 Residuals of traumatic brain injury (TBI):

There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI),

emotional/behavioral, and physical.

Each of these areas of dysfunction may require evaluation.........................

Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain.

Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing,

self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive.

Not all of these brain functions may be affected in a given individual with cognitive impairment,

and some functions may be affected more severely than others.

In a given individual, symptoms may fluctuate in severity from day to day.

Evaluate cognitive impairment under the table titled

``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.''....................................

Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction.

Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment,

under the subjective symptoms facet in the table titled ``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.''

However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms,

rather than under the ``Evaluation of Cognitive Impairment and Other

Residuals of TBI Not Otherwise Classified'' table..........

Evaluate emotional/behavioral dysfunction under Sec. 4.130

(Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder.

When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled

``Evaluation of Cognitive Impairment and Other Residuals of

TBI Not Otherwise Classified.''............................

Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code:

Motor and sensory dysfunction, including pain, of the extremities and face;

visual impairment; hearing loss and tinnitus; loss of sense of smell and taste;

seizures; gait, coordination, and balance problems; speech and other communication difficulties,

including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions...................

The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI.

For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under Sec. 4.25 the evaluations for each separately rated condition.

The evaluation assigned based on the ``Evaluation of Cognitive Impairment and Other

Residuals of TBI Not Otherwise Classified'' table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations....

Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment),

being housebound, etc.........................

Evaluation of Cognitive Impairment and Subjective Symptoms-----

The table titled

``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified''

contains 10 important facets of TBI related to cognitive impairment and subjective symptoms.

It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level,

the highest level of impairment, labeled ``total.''

However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than ``total,'' since any level of impaired consciousness would be totally disabling.

Assign a 100-percent evaluation if ``total'' is the level of evaluation for one or more facets.

If no facet is evaluated as ``total,'' assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent.

For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet.......................................

Note (1):

**** There may be an overlap of manifestations of conditions evaluated under the table titled ``Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified''

with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code.

**** In such cases, do not assign more than one evaluation based on the same manifestations.

If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions.

However, if the manifestations are clearly separable, assign a separate evaluation for each condition..............................

Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.................................................

Note (3): ``Instrumental activities of daily living'' refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone.

These activities are distinguished from ``Activities of daily living,'' which refers to basic self- care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet..

Note (4): The terms ``mild,'' ``moderate,'' and ``severe''

TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of

injury rather than to the current level of functioning.

This classification does not affect the rating assigned under diagnostic code 8045.................................

Note (5): A veteran whose residuals of TBI are rated under a version of Sec. 4.124a, diagnostic code 8045,

in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045.

A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however,

in no case will the award be effective before October 23, 2008.

For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.....................

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Ok! I think Im slowly starting to understand what your getting at.

The cognitive impairment has to be clearly separated from PTSD,and caused by the TBI by itself?

"It's the other way around, memory loss due to PTSD and not TBI -

that is what the examiner stated that helped shoot down your claim for TBI" Yeah , that was from the C&P exam when I re-opened the claim for TBI. I was still waiting on the results from the neuropsych testing when I had that c&p. I think I screwed myself on that one. I remember receiving the VCAA letter, but I never responded to it. That was the first time I never responded to a VCAA. I just let time go by and they made a decision. Stupid on my part! I also seem to remember though it took a very long time to get the results. I think it was way over 30 days. They really dragged out my psych testing. It was done over the course of 3 different appointments. Instead of doing the entire 4 hour test in one sitting. That was probably a good think though. I dont think i could have sat still that long anyways to be analyized.

I guess I will just cross my fingers and wait for the appointment I have coming up. I called the 800# and they said they are scheduling a "medical appointment" for me. I think that is for the TDIU evaluation.

Will they make me go to another C&P for the TBI, even though I have results from a very thourogh psych test?? I would think a rater would value my TBI doctors testing over a C&P examiner's "opinion". No big deal I guess, if I have to go to one. They arent that long and nothing has changed since, I wouldn't be surprised if it has gotten a little worse! Thank you Carlie for taking the time out of your day/night to help me understand what Im up against.

iron,

I don't mean,"What do you mean by PTSD-due to memory loss?? "

It's the other way around, memory loss due to PTSD and not TBI -

that is what the examiner stated that helped shoot down your claim for TBI.

In the information you've just posted, I can see medical evidence that the

doctor has fully supported with full medical rationale, that should help enable your

claim for TBI to be granted.

What I was trying to get across was my opinion that,

being you are already compensated for your memory loss by way of receiving 50 % for your PTSD.

I feel the VBA would say that compensating you for memory loss twice,

( 1 way by comping PTSD at 50 % and 2nd by comping for memory loss due toTBI )

would be pyramiding.

You posted, " My memory is not messed up because of PTSD! "

In your NOD that you posted you state,

"The examiner provided an opinion that my memory impairment was not related my TBI

but was related to the mental disability."

The probability is - in reality that your memory loss is co-morbid with PTSD and TBI.

Next - PTSD doesn't even comp at 60 %.

All mental disorders (except eating disorders) comp at - 10 - 30 - 50 - 70 - or 100 %.

I think the best thing you can do regarding your claim/appeal for TBI is to look over the medical criteria for

DC 8045 - TBI and compare the symptoms and findings shown in your new medical evidence (from the TBI Clinic/Neurologist) with the 8045 criteria.

Maybe I'm off base, I too have TBI and PTSD and my memory can get screwed up too : )

Here's the 8045 criteria :

8045 Residuals of traumatic brain injury (TBI):

There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI),

emotional/behavioral, and physical.

Each of these areas of dysfunction may require evaluation.........................

Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain.

Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing,

self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive.

Not all of these brain functions may be affected in a given individual with cognitive impairment,

and some functions may be affected more severely than others.

In a given individual, symptoms may fluctuate in severity from day to day.

Evaluate cognitive impairment under the table titled

``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.''....................................

Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction.

Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment,

under the subjective symptoms facet in the table titled ``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.''

However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms,

rather than under the ``Evaluation of Cognitive Impairment and Other

Residuals of TBI Not Otherwise Classified'' table..........

Evaluate emotional/behavioral dysfunction under Sec. 4.130

(Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder.

When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled

``Evaluation of Cognitive Impairment and Other Residuals of

TBI Not Otherwise Classified.''............................

Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code:

Motor and sensory dysfunction, including pain, of the extremities and face;

visual impairment; hearing loss and tinnitus; loss of sense of smell and taste;

seizures; gait, coordination, and balance problems; speech and other communication difficulties,

including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions...................

The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI.

For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under Sec. 4.25 the evaluations for each separately rated condition.

The evaluation assigned based on the ``Evaluation of Cognitive Impairment and Other

Residuals of TBI Not Otherwise Classified'' table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations....

Consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment),

being housebound, etc.........................

Evaluation of Cognitive Impairment and Subjective Symptoms-----

The table titled

``Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified''

contains 10 important facets of TBI related to cognitive impairment and subjective symptoms.

It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level,

the highest level of impairment, labeled ``total.''

However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than ``total,'' since any level of impaired consciousness would be totally disabling.

Assign a 100-percent evaluation if ``total'' is the level of evaluation for one or more facets.

If no facet is evaluated as ``total,'' assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent.

For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet.......................................

Note (1):

**** There may be an overlap of manifestations of conditions evaluated under the table titled ``Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified''

with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code.

**** In such cases, do not assign more than one evaluation based on the same manifestations.

If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions.

However, if the manifestations are clearly separable, assign a separate evaluation for each condition..............................

Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.................................................

Note (3): ``Instrumental activities of daily living'' refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone.

These activities are distinguished from ``Activities of daily living,'' which refers to basic self- care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet..

Note (4): The terms ``mild,'' ``moderate,'' and ``severe''

TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of

injury rather than to the current level of functioning.

This classification does not affect the rating assigned under diagnostic code 8045.................................

Note (5): A veteran whose residuals of TBI are rated under a version of Sec. 4.124a, diagnostic code 8045,

in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045.

A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however,

in no case will the award be effective before October 23, 2008.

For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.....................

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