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Effective Date Of Claim


Ricky

Question

In Feb 03 I filed a claim for an increased rating for a back problem. My back injury was SC at zero percent. In a July 05 rating VA denied my claim. I submitted a NOD in Aug 05. In Jan 06 VA approved a 10 percent rating for my back with an effective date of Jan 06. I think the effective date should have been Feb 03 the date of the original claim. I did not miss any dates for the NOD ect......... The same rating approved an increase in my SC hypertension from 10 to 20 percent effective Feb 03. I do not know what they did. Should I file another NOD on the effective date? Thanks

Ricky

Forgot to mention: The back claim is included in my Feb 06 formal appeal (VA9). However, the only issue appealed was the rating percentage. I feel it should have been 20 percent vs the 10 they gave. I did not notice the effective date until last night while reviewing my claim. Will a NOD mess up my formal appeal? how should I handle this. Thanks

Edited by Ricky
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Your dang skippy!! If you didn't miss any dates they are to go back to the date of the service connected item(s) on your original claim submission. I would simply make it clear that although you were disagreeing with their rating decision that that is all the NOD was addressing, something that was incorrectly rated.

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General Rating Formula for Diseases and Injuries of the Spine

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated

under the Formula for Rating Intervertebral Disc Syndrome Based

on Incapacitating Episodes):

With or without symptoms such as pain (whther or not it

radiates), stiffness, or aching in the area of the spine

affected by residuals of injury or disease

Unfavorable ankylosis of the entire spine............... 100

Unfavorable ankylosis of the entire thoracolumbar spine. 50

Unfavorable ankylosis of the entire cervical spine; or, 40

forward flexion of the thoracolumbar spine 30 degrees

or less; or, favorable ankylosis of the entire

thoracolumbar spine....................................

Forward flexion of the cervical spine 15 degrees or

less; or, favorable ankylosis of the entire cervical

spine.................................................. 30

Forward flexion of the thoracolumbar spine greater than

30 degrees but not greater than 60 degrees; or, forward

flexion of the cervical spine greater than 15 degrees

but not greater than 30 degrees; or, the combined range

of motion of the thoracolumbar spine not greater than

120 degrees; or, the combined range of motion of the

cervical spine not greater than 170 degrees; or, muscle

spasm or guarding severe enough to result in an

abnormal gait or abnormal spinal contour such as

scoliosis, reversed lordosis, or abnormal kyphosis..... 20

Forward flexion of the thoracolumbar spine greater than

60 degrees but not greater than 85 degrees; or, forward

flexion of the cervical spine greater than 30 degrees

but not greater than 40 degrees; or, combined range of

motion of the thoracolumbar spine greater than 120

degrees but not greater than 235 degrees; or, combined

range of motion of the cervical spine greater than 170

degrees but not greater than 335 degrees; or, muscle

spasm, guarding, or localized tenderness not resulting

in abnormal gait or abnormal spinal contour; or,

vertebral body fracture with loss of 50 percent or more

of the height.......................................... 10

The above is the general rating schedule I was rated under 5237 Lumbosacral or cervical strain

Edited by Ricky
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  • HadIt.com Elder

.

There is another section (can't find it now) on the back that gives more info and different ratings than those posted below.

It goes from 10% or 20% ... to a max of 60% (if I remember correctly) ????

It reads very differently from what is posted here.

... Magoo .. aka .. Bill ... :)

PS: I am at 40% for back injuries now and my next step up is 60%, I think ... or it was under the old books that I had.

At 60% for back ... I think that I can add that to the 100% and qualify for SMC ... ?????

I just can't remember where that info. is at the moment.

... Magoo .. aka .. Bill ... :wacko:

.

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  • HadIt.com Elder

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rickb54:

You brought up a good point on the old rules and the new rules.

I was also rated under the old rules.

I see no 60% under the rules posted below and that would be my next step up (under the old rules) from my present 40%.

(Going from 40% to 50%, on the back injuries will not get me to SMC)

If I ever applied for an increase ... would I be grandfathered under the old rules or would the new rules apply to my new application for an increase ???

By leaving out a 60% rating ... that makes it impossible for me to get to 60% on the back and get SMC then ??? ... (100% + 60% needed for SMC)

(I am presently at 100% + 40% + 10%)

Rick ... I think we discussed back injuries a long time ago .. and Mike H. posted some old ratings for us ??

Thanks for your input ....

... Magoo .. aka .. Bill ... :)

.

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The rating criteria for the spine changed in Septemeber 2002, so If you filed a claim prior to that date and your claim was decided after the change, as Rickb54 said, the VA would use either the old criteia or the new criteria, whichever results in the higher rating.

Now if you are rated under the old criteria and file for an increase, you'll also be rated under either the new criteria or the old criteria, depending on which will result in the higher rating.

Mr. Magoo, what you are refering to in regards to the "other section" is the seperate rating criteria under the new rules for IVDS. These ratings apply to such conditions as HNP, bulging disc ect... and are based on incapacitating episodes. Incapacitating episodes, according the new rules, are days of prescribes besd rest and treatment by a physician. Down below are both the old rating criteria and the new;

rating criteria prior to Sept. 2002;

5289; Spine ankylosis of, lumbar

Unfavorable....................................50%

Favorable.......................................40%

5290: Spine, limitationof motion, cervical

Severe..........................................30%

Moderate......................................20%

Slight.............................................10%

5291: Spine, limitation of motion of, dorsal

Severe...........................................10%

Moderate........................................10%

Slight..............................................0%

5292: Spine, limitation of motion, lumbar

Severe............................................40%

Moderate.........................................20%

Slight..............................................10%

5293: Intervertebral Disc Syndrome

Pronounced: with persistant symptoms compatible with sciatic neuropathy with characteristic pain

and demostrable muscle spasm, absent ankle jerk, or other neorological findings appropriate to

site of diseased disc, little intermittent relief......60%

Severe, recurring attacks, with intemittent relief....40%

Moderate, recurring attacks.............................20%

Mild...............................................................10%

Postoperative, cured........................................0%

5294: Sacro-iliac injury and weakness

5295; Lumbosacral srain

Severe, with listing of whole spine to opposite side, positive Goldwait's sign, marked limitation of

forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing

or irregularity of joint space, or some of the above with abnormal mobility or forced motion.....40%

With muscle spasm on extreme forward bending, loss of lateral spine motion unilateral, in standing

position...............................20%

With characteristic pain on motion.......10%

With slight subjective symptoms only......0%

New rating criteria after Sept 2002

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes):

Unfavorable ankylosis of the entire spine...100%

Unfavorable ankylosis of the entire thoracolumbar spine...50%

Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine...40%

Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine...30%

Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis...20%

Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height...10%

Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.

Note (4): Round each range of motion measurement to the nearest five degrees.

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

5235; Vertebral fracture or dislocation

5236; Sacroiliac injury and weakness

5237; Lumbosacral or cervical strain

5238; Spinal stenosis

5239; Spondylolisthesis or segmental instability

5240; Ankylosing spondylitis

5241; Spinal fusion

5242; Degenerative arthritis of the spine (see also diagnostic code 5003)

5243; Intervertebral disc syndrome

Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25.

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes

With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months...60%

With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months...40%

With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months...20%

With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months...10%

Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment.

As one can see, with the old rating criteria, there was too much inconsistencies in the ratings. that's why the VA modified the criteria. Now there are precise measurements to go by. Also under the old criteria, it was unclear whether disabilities from neurological symptoms could be rated seperatley without pyrmiading. Now, under the new criteria that is specifically spelled out. Simply put, the old criteria was just too vague on many issues.

Vike 17

Edited by Vike17
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