Pstd Imo Letter -- Doctor Can't Write Decent Letter. Aleady Sunk $1000 Into This...

[DrBarbae]

Hello all,

First post here. I have a long story to start with that leads up to some simple questions...

I am SC'd 30% for PTSD, but have filed a NOD. To bolster that NOD with new evidence, I am paying out of pocket for an Independent Medical Opinion (IMO). I chose a doctor than had experience with forensic psychology that had an impressive background based on my Internet research. Well, I converse with him back and forth through email a few times, told him I wanted to meet him for treatment, psychometrics, examinations, etc, then get a report for the VA as a result of our meeting. I asked if he was familiar with the right verbiage to "answer the mail" for the VA, and he said yes; he would charge me $1000 for it all. Well, fast forward a few week later, I have the appointment, pay him the $1000, and now I have the report.

In short, the report does not answer the mail (I explain why in a bit), and I am not that certain that he would be capable of putting the report with the right verbiage, even if I told him what was needed. It's a lot like asking a kindergartner to write a doctoral thesis---it is just not possible. First of all, my last name is inconsistently spelled throughout the report, and the grammar is terrible. The details I provided are vague or missing, especially with what I painfully shared regarding my main PTSD stressor. When asked if I had any thoughts of suicidal ideation, I admitted I had thought of a plan, but have never attempted it (in the report, it mentions I denied any suicidal ideation). I think you all get the picture---there is no beef to this report to make it supportive of any case I would make, whether that my PTSD has gotten better, worse, or stayed the same. Ineed the professional product I paid for if I want to get anywhere with the VA.

Because of this, the only practical way of moving forward with this is if I write the letter, and he sign it. The doctor is likely amenable to this based on some of the conversation we had before I left the office. Thus, I have retyped his letter, and put in the details that need to be there. This feels quite awkward, and is a situation I did not expect or want to find myself in. Since I have already sunk $1000 into this and several weeks of my time, I don't want to start over. I just want to get this behind me and not play this back-and-forth game with the VA for years or decades like my dad did. I just want an effective letter that is quite clear about the findings and submit my new evidence.

Ok....so now the questions:

Is this "letter writing" on behalf of doctors that don't know how to write for the VA common by vets that are gathering new evidence to support a claim?

Is the following quoted statement at the end of the letter with the diagnosis normal? "The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

What should I do in this situation? Any suggestions or comments?

Thanks!

[Berta]

This is why we have an IMO format here with the proper wording an IMO doctor should use.

“Is this "letter writing" on behalf of doctors that don't know how to write for the VA common by vets that are gathering new evidence to support a claim? “

Not if they get an IMO doctor who follows the proper format and,better yet, has already prepared IMOs for VA purposes.

“Is the following quoted statement at the end of the letter with the diagnosis normal? "The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

Can you scan and attach the letter here ?(Cover all identifying info)

Did this doctor go through and refer to your complete medical records in the IMO?

“What should I do in this situation? Any suggestions or comments? “

I certainly do NOT suggest writing the letter for the doctor to sign.

My husband went from 30% SC PTSC to 100% SC PTSD P & T.

I referred to his entire established “evidentiary” medical record as well as many psychiatric test results from a VA shrink that were not part of his formal medical record.

That increase involved a considerable amount of medical documentation that had developed since his original rating.

PTSD stressors, once conceded by VA, are no longer an issue in any request for a higher rating.

Maybe the IMO is actually OK. Hard to know without seeing it. But the typos and spelling problems should be corrected before VA sees it.

“38 CFR § 4.130-2"

What did the doctor mean by the '-2' reference?

Did the doctor give you a CV with the opinion?

[broncovet]

I guess what you are suggesting is that the VA low balled you, with the 30%, and you are trying to get it increased, and you wish to preserve the effective date by filing a nod.

And, you need help writing the letter, because you think the IMO doc does not have a clue.

Since you are apparently writing the letter yourself, and you have already paid for it, do it this way, as a suggestion, instead:

Go to the mental health schedule of rating disabilities:

It is available here, and the "top 2" ratings are below:

http://www.vva.org/ptsd_levels.html

Then, write down each symptom you have, especially those you reported to docs.

Take these two lists (the desired rating and your symptoms) and match them up, as much as possible, of course, being honest and not exaggerating. Here are the top 2 PTSD rating criteria:

38 C.F.R. § 4.130, DC 9411

GENERAL RATING FORMULA FOR MENTAL DISORDERS:

Total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation occupation, or own name …………………..100%

Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships ...................................... 70%

You see, the VA HAS to rate you on the criteria. If they rate you based on the color of your ball cap, then you should be able to appeal it successfully. Match YOUR symptoms up to the criteria, reminding you the case law suggests you do not have to meet ALL the criteria but instead, as the judges say it, "your symptoms most closely approximate the .......percent rating criteria.

[broncovet]

Also, are you working? If you are presently working, its gonna be tough to justify a 100 percent rating, noting the criteria calls for total occupational (and social) impairment, noting the word "and" in the criteria, not "or".

If you are NOT working, and have not have "substantial gainful employment" for some time, due to SC conditions, then you should be able to eventually win either TDIU or 100%, but your IMO should explain why you cant work, such as:

Veteran is currently unemployed and it is highly unlikely that he will be able to obtain substantial gainful employment because:

1. He must attend multiple doctor appointments per week, interfering with work schedule.

2. His irrational behaviour precludes working. For example, (list some of your symptoms, such as violent tendencies, suicidal ideation, inability to get along with others, memory loss, etc. etc.

3. Veteran presents a danger to self or others (SI, HI).

4. Veteran lacks an ability to concentrate for an 8 hour period, such as the flattened affect. etc, etc.

[Berta]

Broncovet raised some important points.

To add to my post-- you mentioned psychometric testing,

For 1,000 bucks, did the Dr. give you the written test results assessment?

I used the results of 6 or 7 psychiatric tests of this type for my husband's claim.

As I think I mentioned, they were not in his medical record file but done by the head VA psychiatrist.

(after a battle- VA doesn't like to pay for this type of extensive MH testing)

The VA doctor had written the results up in one single 2 page assessment.

I am sure the SSDI had these test results but ,somehow they were never in my copy of his VA med recs.

These involved Trails Mosing, MMPI -Combat related, the Hand Test, Weschler test, and a few other tests VA did over a 2 day period.

They were done to assess and separate my husband's PTSD from a major CVA (stroke) and resulted in the 100% SC PTSD award (1997)

as well as a 1151 100% award for his stroke. (Jan 2012)

VA can quibble with any IMO and give an IMO little or no weight against the C & P they based the 30% on., as,in your case, but these test results might be all you need to support a higher PTSD rating.

Another point. I subsequently got 2 IMos for a different claim and I made sure my IMO doctor had the C & P results VA used the deny the claim as well as the SOC and SSOC that claim generated.

With the results of a VA C & P, and the VA's interpretation of a C & P in a decision, any IMO doctor has a better chance of knocking that opinion down,if it is medically deficient - with a full medical rationale.

Edited July 8, 2012 by Berta

[carlie]

Hello all,

First post here. I have a long story to start with that leads up to some simple questions...

I am SC'd 30% for PTSD, but have filed a NOD.

What is the date of your rating decision that granted PTSD as SC'd at 30 percent?

To bolster that NOD with new evidence, I am paying out of pocket for an Independent Medical Opinion (IMO). I chose a doctor than had experience with forensic psychology that had an impressive background based on my Internet research. Well, I converse with him back and forth through email a few times, told him I wanted to meet him for treatment, psychometrics, examinations, etc, then get a report for the VA as a result of our meeting. I asked if he was familiar with the right verbiage to "answer the mail" for the VA, and he said yes; he would charge me $1000 for it all. Well, fast forward a few week later, I have the appointment, pay him the $1000, and now I have the report.

Minus your personal info like name, claim #, address, DOB, etc . . .

What EXACTLY does this "report" state and what exactly is this doc's pedigree?

In short, the report does not answer the mail (I explain why in a bit), and I am not that certain that he would be capable of putting the report with the right verbiage, even if I told him what was needed. It's a lot like asking a kindergartner to write a doctoral thesis---it is just not possible. First of all, my last name is inconsistently spelled throughout the report, and the grammar is terrible. The details I provided are vague or missing, especially with what I painfully shared regarding my main PTSD stressor.

Being that you are ALREADY SC'd for PTSD and this is a claim for increase -

evidence relating to your "main PTSD stressor" is irrelevant.

That time is done and over.

In your claim for increase what IS relevant is your current condition and how

your mental health symptomology from your PTSD effects your Occupational and Social life.

To be blunt - at this point, it no longer matters if your in service stressor shows you killed or saw killed

10,000 individual bodies - mid air collisions - IED's - horrible personal assault, what ever your specific

situation/triggering event was - it's no longer relevant in your claim for increase.

When asked if I had any thoughts of suicidal ideation, I admitted I had thought of a plan, but have never attempted it (in the report, it mentions I denied any suicidal ideation). I think you all get the picture---there is no beef to this report to make it supportive of any case I would make, whether that my PTSD has gotten better, worse, or stayed the same.

I need the professional product I paid for if I want to get anywhere with the VA.

You can try to get the doc to write a different "report" or amend the one already written.

Because of this, the only practical way of moving forward with this is if I write the letter, and he sign it. The doctor is likely amenable to this based on some of the conversation we had before I left the office. Thus, I have retyped his letter, and put in the details that need to be there. This feels quite awkward, and is a situation I did not expect or want to find myself in. Since I have already sunk $1000 into this and several weeks of my time, I don't want to start over. I just want to get this behind me and not play this back-and-forth game with the VA for years or decades like my dad did. I just want an effective letter that is quite clear about the findings and submit my new evidence.

It's best to be in both doc (medical) and va (schedule of rating) lingo.

Also, are you in therapy? If yes, have you discussed any of this with your MH provider?

Did you ask your provider for a letter of support?

If you are not in therapy, I suggest receiving some continuous for of MH treatment/therapy.

Ok....so now the questions:

Is this "letter writing" on behalf of doctors that don't know how to write for the VA common by vets that are gathering new evidence to support a claim?

Is the following quoted statement at the end of the letter with the diagnosis normal? "The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

Many VA and SSA claimants do go get IMO's, that is an individual decision and is quite often

needed to advance a claim issue.

I feel that where it states,

"The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

is just a blanket and generalized statement and is not sufficient to garner an increase.

The provider needs to specifically state and address the hows and whys of the deficits that your MH symptomology,

has on your current Occupational and Social functioning.

JMHO - carlie

What should I do in this situation? Any suggestions or comments?

Thanks!

[DrBarbae]

All,

Here is the report in full, below the asterisks. I also attached it as a file.

To all: I really appreciate the replies and the helpful advice. I’ll respond to some of the replies I got when I get a minute later today, but want to get this letter out here first. Any comments on it in the meantime?

Will this letter make much a difference if I am filing for an increase from 30%?

DB

**** **** **** ****

Evaluation Report On Mr X

Referred to this examiner upon inquiry from nearby hospital X was formerly in the military for 11 years and earned the rank of X. He suffered Post Traumatic Stress Disorder and was seeking re-assessment for the classification of disability.

During the process, Mr. X exhibited a capacity for independent functioning and cooperated with the evaluation enough to provide useful interpretive information.

He was administered two (2) Structured Clinical Interviews, Mini Mental Status Examinations [MMSE], and the Minnesota Multiphasic Personality Inventory-2 [MMPI-2]

Presentation

Mr. X currently resided in X and worked approximately 80 hours/week, he said. He had desk-job and did not consider it to be too demanding, considering the he worked long hours. He felt fortunate to have private living quarters where can resort to watching movies, personal pleasures, and fitness training. Mr X claimed to enjoy the “simple life” in X.

Mr. X reported pessimistic cognitions and always feeling “on edge”. He believed the worst would happen to him. Generally, his mood appeared to be low most of the time, he added.

Since 2004, Mr. X has been suffering from frequent anxiety attacks that occurred twice/week. He indicated that e-mails and the ringing of a phone trigger the onset of anxiety symptoms. During such attacks, he would feel “heartbeat racing faster” [palpitations], physically hot and sweaty; in addition there would be a lack the ability to concentrate for a few minutes during and after the attack. Mr. X has no problems with short-term or long-term memory.

Specific Stressor

Mr. X described the he had five (5) near-death experiences that “were horrific”. The first and most traumatic incident which occurred in 2004 was in Iraq. Following was his description:

“I was sleeping. All of a sudden I woke up startled to a loud noise. I just froze there. I did not know how to react. It’s like I lost perception of time. You wouldn’t understand. You’d have to be there. I was quite shaken up.”

Family background

Mr. X originated from X city, and came from a middle class socio-economic class family. He referred to his childhood as “good and innocent”, in which his father and mother worked hard to provide for the family. His father passed away at the age of 57 due to a heart attack. His mother re-married. His younger sister, who is 5 years younger, is currently married.

He claims to have no close ties to any family members and feels indifferent towards their behavior. Family history appears to be void of psychiatric/mental illness, although Mr. X believes his mother may be depressed.

He met his partner online [internet] and they were married for approximately 2 years, obtaining a divorce in 2008. Mr. X admitted that his ex-wife would describe him as “controlling, demanding, and short-tempered”. He revealed that the divorce upset him very much but now indicated feeling “indifferent”.

History Brief

Earning a high school diploma, Mr X described himself as an average student. He claims ho have had a few close friends throughout his school years. Due to the nature of his work, he lost contract with them and has no idea of there whereabouts. As a young boy, he wanted to be an engineer. At the age of 20, Mr X decided to go the military. After serving 11 years in the military, he requested an Honorable Discharge. He was faced with “unnecessary and reasonable demands” as well as “extremely stressful situations”.

Mr. X suffered from the medical condition Alopecia, which refers to loss of hair from the head or body. Information on his medical history must be obtained from his physician.

He reported occasional consumption of alcohol, 3 beers per month, and there is no indication of substance use or abuse patterns. Mr. X did not report a criminal record or any legal issues.

Interpersonal relations

He has a difficulty in establishing and maintaining friends. Also, Mr X lacks the interest and motivation in initiating conversations in social settings. He seems detached from any interpersonal relationships.

Seeming to have poor social skills, Mr X was unable to relate to other people comfortably. He is dependent, over controlled, and unable to express or assert himself adequately. He tended to withdraw from unpleasant social situations and cold spend a great deal of time and energy in fantasy and rumination. He reportedly felt chronically inadequate and seemed incapable of relating to others on an equal, mature basis. He also had strong feelings of sexual inadequacy.

This can result in being self-absorbed and unskilled in gender-role behavior. To develop a rewarding intimate relationship would be difficult.

Mr. X is a highly introverted and interpersonally avoidant person who feels very uneasy in close interpersonal involvements, although he can act extrovert for a short period of time in a given situation. His emotional detachment appeared to be long-standing in duration. He appeared to be insecure, lacked self-confidence in social situations, and becomes quite anxious around people. Typically rigid and over controlled Mr. X tended to worry a great deal and experience periods of low mood in which he would withdraw significantly from others.

Summary

When answering clinical interview topics and psychometric items for this psychological intervention, the some endorsements were intense as a result of careful item response pattern. He apparently understood the items content and considers the symptoms descriptive of his current functioning.

His self-description as disturbed required further consideration because he claimed many more symptoms than most patients do. Two likely possibilities require further evaluation. It is possible that he overstated his symptoms as a result stress and the need to seek a great deal of attention for his problems.

Exaggerated response set can be ruled based on life circumstances, it may be that his extreme responding resulted from psychological troubles.

Mr. X is apparently experiencing a great deal of psychological distress, including tremendous anxiety, tension, and repetitive thoughts of self-doubts. He appeared to be experiencing an intense period of anxiety at this time, compounded by a chronic problem of maladjustment and difficulty fitting into society.

He reported sleep disturbance and was bother by feeling inadequacy and guilt. Mr X maw having difficulty concentrating and making decisions. Pre occupied with his problem and precarious in his adjustment, he appeared to have difficulty controlling his thinking.

He showed a meager capacity to experience pleasure in life. The tendency to be pessimistic rendered a world view in a highly negative manner, developing a worst-case scenario to explain events affecting him. Mr. X tended to worry and interpret events as problematic. His self-critical nature prevented him from viewing relationships possibilities positively.

Mr. X is impacted by symptoms of Post Traumatic Stress Disorder affecting his social functioning. This was also contributory to high levels of anger control.

The Mini Mental Status Examination was with normal limits and showed no neuro-psychological issues at the time of this assessment. He responded logically and appropriately. No sign of memory impairment. Psychotic episodes were not cited. Suicidal and homicidal intent was not indicated in his history, nor reported by Mr. X.

Diagnosis

AXIS I: Post Traumatic Stress Disorder [DSM-IV-TR 309.81]

AXIS II: none specified

AXIS III: Alopecia

AXIS IV: Psychosocial problems occurring contribute to the mental health issues that lead to PTSD.

AXIS V: Current GAF = 51 due to PTSD [overly cautious, depression, anxiety, hypervigilance, exaggerated startle response, intrusive thoughts, irritability, internalized anger, sleep disturbance due to obsessional cognition, stress over simplicities, lack of emotional connectedness, apathy, social isolation preference]

This report is submitted.

Respectfully

Dr. Y

hadit redact.doc