Jump to content
VA Disability Community via Hadit.com

VA Disability Claims Articles

Ask Your VA Claims Question | Current Forum Posts Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users

  • hohomepage-banner-2024-2.png

  • 27-year-anniversary-leaderboard.png

    advice-disclaimer.jpg

  • donate-be-a-hero.png

  • 0

Psoriasis 30% Rating - Nod Decision Received - Advice Wanted

Rate this question


HawaiiJ

Question

Hello, I’m looking for some guidance and understanding on one of the Service Connected issues I have. I’ll apologize in advance if I get long winded but will do my best provide the timeline and decisions along the way. Here’s a simple timeline.

Jan 2009 - Retired USAF

Jun 2009 - VA Received initial VA Claim for Disability

Dec 2009 - VA Examination at the VAMC Boston

May 2010 - Notified of Decision

Apr 2011 - NOD Received at VA

Oct 2012 - NOD Decision sent to Claimant

I agree with all my SC decisions made by the VA with one exception: PSORIASIS, initially determined to be 30% disabling. My opinion based on evidence provided, it should have been 60%.

The May 2010 decision was for 30% disability for Psoriasis was based on 20% of the body and the it goes on to include all the other technical terms related to a Psoriasis decision.

The decision noted that my Psoriasis is treated with 50 milligrams of Embrel twice per week which has been effective.

The Embrel injections started in Nov 2007. This was after countless treatments with all the cream, suave & solution therapies available. It also included a two regimens of Cyclosporine which worked wonders until stopped and the Psoriasis conditions came back with a vengeance. FYI - My issue with Psoriasis date back to 1994.

The following paragraph was included in the decision as well in the initial decison:

“an evaluation of 30% is assigned from January 1, 2009. An evaluation of 30% is granted for evidence showing 20 to 40 % for the entire body or 20 to 40% of exposed areas affected, or; systemic therapy such as corticosteriods or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A higher evaluation of 60% is not warranted unless evidence shows more than 40% of the entire body or more than 40% of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period.”

That was the 30% decision and how to increase to 60% if warranted. My understanding of the decision was something had been missed on the immunosuppressive drug therapy-EMBREL. I had began taking Embrel in Nov 2007 which was nearly 18 months of use at the time I filed the initial VA Claim. Embrel is clearly described as an immunosuppressive drug on the drug manufacturers website and others related to Psoriasis info. My twice weekly injections were constant meaning this was the dosage and use prescribed by my doctor.

I felt this was a clear miss on the VA’s part. Embrel was in use for longer that the “constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period” threshold described in the VA decision.

So, I decided to file a NOD, requesting the higher 60% decision based on the use of immunosuppressive drug therapy. I’m thinking this is easy, I state the obvious, provide clear dates with evidence and should be a simple correction to the 60% rating.

Also, It should be noted between the initial decision and filing the NOD the Embrel stopped working and I began taking STELARA which also decreases and impacts your immunosuppressive system in a negative way too. All this information was provided in the NOD filing and it showed a continuous use of EMBREL and STELARA from Nov 2007 until the date of the filing. Well over the 12-month use threshold required for 60% rating. To date I’m still using STELARA and the VA is currently paying 100% the cost of this therapy via their Foreign Medical Program (VA-FMP).

On 22 Oct, 2012 the NOD decision was received the VA decision was to maintain the 30% disability rating based on the exact same reasoning listed in the original decision and also the NOD decision included the same comments about what warranted a higher 60% rating which stated: “constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period”. No progress was by filing the NOD. The VA came to the same decison without clearly stating Embrel use was involved in the decision.

Ok, thats the story here’s a few questions I need help on understanding if anyone has a recommendation. I have 60 days to make a decision to appeal, disagree or request a hearing in person.

1. What qualifies as: constant or near-constant systemic therapy such as corticosteriods or other immunosuppressive drugs required during the past 12-month period? Does constant use as prescribed by doctor from 2007-present meet definition of constant or near-constant?

2. EMBREL and STELARA both suppress the immune system this is based on the drug information listed on the manufacturer’s sites. Why does this not meet the VA threshold for immunosuppressive therapy?

3. What am I missing?

4. Am I foolish for thinking I should be at 60%?

5. Would a BVA hearing be a mistake or am I chasing something I can’t catch?

Sorry for the long version, hopefully I have provided enough info without clouding the issue too much. Looking forward to the replies. Thanks.

Link to comment
Share on other sites

Recommended Posts

  • 0

Another quick update. I'm back in Florida and had a experience getting indoctronated into the VA medical center for care for this Psoriasis problem.

I went through the PCP in Lake City (Very good experience) and got referred to Gainsville to see a dermatologist. The goal was to get into the system before my next shot of Stelara was due. During the Dermatology consult, the Doctors were great, very pleased I had extensive medical records on the history of my Psoriasis battles. Dueing the consult my point was I wanted the VA to continue to pay for my Stelara injections since they had been paying while I was living overseas in Thailand (Via the FMP program). The Doctor agreed, this makes sense and we proceeded to make it happen.

I had provided 3 years of VA Explaination of Benefits proving the VA had been paying the Stelara bill for 3 years and I had been on Stelars for over 5 years.

They the Doctor called me 3 days later and said the Pharmacist denied the request because I had only failed one other injectable (Enbrel) and not the Humira option. So the Pharmacist approved a 90 day test of Humira to see how I would respond to the change. Needless to say I was not over-joyed. After all, I had been taking Stelara for 5+ years and the VA footed the bill for 3 years.

I was at a loss as what to do..I had very little options in terms of how to change this decision.

During the Veteran's Symposium I attended here in my local town I spoke to the VA folks from the VA Clinic in Tallahassee. After expressing my frustrations, it was mentioned I should call the patient advocate to discuss the change from Stelara to Humria.

So when I contacted the Patient Advocate, I requested some one from the Pharmacist call me to make sure they fully understood my situation (Taking Stelara for 5 years/VA paying for it for 3 years). I got a call form the head of the Pharmacy department who listed to my explaination and reasoning and desire to not changing medication after 5 years of success. He listened and agreed and said there was no need to change and he would approve the Stelara injections.

The Dermatology doctor called again and we talked and he understood my position and was supportive of the decision and my actions.

Now I'm getting the Stelara via the VA back here in the USA.

Needless to say, I've been very lucky during my transition back to the USA.

For me the VA care has been very good with no complaints...

Link to comment
Share on other sites

  • 0
  • HadIt.com Elder

The favorable resolution occurred as a result of communication, something that the VA usually seems to be very poor at.

Not to mention that attention from outside the VA often helps tremendously.

Personal efforts also played a large part.

At the moment, the VA is very sensitive to criticism from those who can add fuel to

the fire under the "hotseat" that congress has placed senior VA officials in.

Link to comment
Share on other sites

  • 0

HawaiiJ,

Can I ask how you were able to achieve the initial rating for Psoriasis?  Were you originally diagnosed in service?

I ask because I started out with issues after my deployment for OIF, they inaccurately diagnosed as ezcema first.  After I got out, it was diagnosed as Psoriasis almost 5 yrs later.  I am putting together my case for Psoriasis, but I want to try to make it as airtight as I can.  I am also on Enbrel 2/wk.  And will be using the Patient Advocate to try and get the VA to pay for Stelara.  They refused because I did not try Humera.  I am hesitant to try Humeria because of the most recent illness that was really bad.  I had flu/strep/bronchitis at the same time and it laid me up for 2 wks.  I have kids so I am more susceptible to illness because they bring it home.  Stelara would prevent that.

Any help or advice you could provide would be amazing.

Thanks.

Link to comment
Share on other sites

  • 0
2 hours ago, sealjoy said:

 

Can I ask how you were able to achieve the initial rating for Psoriasis?  Were you originally diagnosed in service?

 

Yes, I was diagnosed while in service. I was also taking Enbrel while in service thanks to my active duty Dr.  He was instrumental in getting the correct diagnosis and not giving up on me during the battle.  I too was misdiagnosed with eczema and luckily this was resolved once and for all via a "punch biopsy" and further confirmation during a referral  visit to an off base doctor in Naples It. 

The initial 30% diagnosis was granted as a result of the Comp/Pen VA Exam, granted for scarring and coverage.  Should have been at 60% because of the clear indication of "immune suppressive therapy" for 12+ months (Enbrel). The VA doc did state Enbrel use but not the length of time I was taking it.

Luckily, after I got out I lived in Boston and selected to use the tricarre alternative "US Family Health Care" system and made the switch from Enbrel to Stelara at no cost.  In 2011, I moved to Thailand and started using the VA's Overseas Tricare". Basically, it was pay upfront and get reimbursed 30-45 days. This allowed me to continue Stelara use with no gaps.  When I returned to the USA in Jan 2015, I reached out to the VA to continue the Stelara and got nothing but support from the doctor at the Gainsville VA.  But the Pharmacist was the hurdle, they insisted on me trying Humeria because their protocol called for a double failure on 2 different biologics before starting on Stelara. 

After getting the initial denial I asked to speak the Pharmacy Department to try to discuss the rational.  TO my surprise, I got the head of the department.  He stated his case and I did mine too.  I got lucky.  Reason was I had been on Stelara 5+ years and the VA had been paying the bill already for nearly 4 years.

With this explained my request for Stelara was granted and he stated he had a hard time taking something away from me that was working and the VA was paying for already.

As for advice, I'm not experienced in working to create the nexus between in service/after service or the incorrect diagnosis.  But I would recommend to have the doctor you use for the claim to make sure it clearly states "immune suppressive therapy" for 12+ months and coverage if possible. 

One of my main points of concerns with the VA exam while taking Enbrel/Stelara is the treatment (in my case) eliminates almost all indicators I have Psoriasis and make it impossible for a Dr to make an observation rating/finding that favors a veteran in a fair manner.  Never have understood the logic of this dilemma.

Good luck with the advocate, they were helpful in getting me in contact with the Pharmacy department and the head resulting in the result I was looking for.  I'm sure I'll have to battle them when Stelara becomes ineffective. 

 

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...

Important Information

Guidelines and Terms of Use