Letter To Ask Ro To Disregard Examiner's Report

[free_spirit_etc]

So would sending this be a good idea? And what suggestions for changes do you have?

Free

C&P Service Clinician’s Guide § 4.2 “1.11 If an examination report does not contain sufficient details to adequately support the diagnoses (unless the diagnosis is already well established) or sufficient information about the current findings and effects on functioning, the RVSR will return the report as inadequate for rating purposes. (38 CFR 4.2)

I consider the examination I received in March 2002 regarding my lung cancer to be totally inadequate for the following reasons and request that it not be used as a basis in determining my case.

1. The examiner did not examine me.

Though the report is labeled as an examination, the examiner never met with me. The examiner indicated in his report that he was requested to offer an opinion after review of the medical records whether there is a relationship between my currently detected lung cancer and exposure to asbestos in the service, or to give an opinion as to any other etiology.

There is nothing in the examiner’s report which indicates he even talked to me, let alone examined me. The VA examiner issued his report / opinion after a review of some of my records. However, issuing such a report as a “Respiratory Diseases, Miscellaneous Exam” is misleading, and could be mistaken for an actual examination under the VA Clinical Guidelines, which it is not.

2. The fact the examiner stated I had no shortness of breath, and did not have any apparent residuals of the lung cancer I was treated for without even examining me raises a legitimate question as to the credibility of his report.

My pulmonary function tests done at the same VA facility on March 19, 2002 (the same day the VA examiner indicated he reviewed my medical records – and five days before he signed the report) noted that I had dyspnea on hills and stairs, frequent wheezing, and decreased FVC (73% predicted) and decreased FEV1 (69% predicted)

According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.).

FEV-1 of 56- to 70-percent predicted should be rated at 30%

The examiner did not even mention my pulmonary function tests done that day, yet he declared I did not have any apparent residuals of the lung cancer. Though it is part of my medical record, it is not clear whether the examiner realized that I had a left lung lower lobectomy before he issued his opinion on my residuals, as he failed to mention it in the report.

My DLCO was 51% on my pulmonary tests at xxx Air Force Base in 2001. These were also part of my medical record. According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.).DLCO (SB) of 40- to 55-percent

predicted should be rated at 60%.

The C&P Service Clinician’s Guide 6.1 d) 4. states “If the DLCO test is not included as part of pulmonary function testing, the examiner should determine whether or not it would provide useful information about the severity of pulmonary functioning in a particular case. If it was not done as part of the routine testing, and would not be useful, the examiner should explain why, e.g., by explaining that the DLCO would not be valid in this particular case because of the decreased lung volumes. Unless an explanation for its omission is provided, the DLCO should be done.”

Though my DLCO’s of record were low, no DLCO was done as part of my pulmonary functioning testing. Nor was there any explanation as to why a DLCO was not done prior to his determination that I had no residuals from lung cancer. Again, I question the adequacy of his report.

As I also have resected ribs, an 11 inch long depressed scar spanning from my scapula to under my arm, etc. I question the ethical soundness of a physician making a determination that I had no residuals of lung cancer merely from reviewing some of my medical records, without so much as seeing me, and without articulating sound medical reasons for doing so.

2. There is no indication that the examiner issued a fully informed opinion based on a complete and thorough review of all the relevant information of record. I would think this would be especially important when issuing an opinion from viewing the files, in absence of examining me.

Though the examiner notes that my service medical records were completely reviewed, he doesn’t articulate any specific post-service medical records that were reviewed. The only post-service medical record the examiner references in his report is the September 2000 pathology report, which indicated evidence of emphysematous changes. As my claim involved post-service diagnosis of disease, which is covered under §3.303(d) , it would seem that a complete and thorough review of my post-service medical records would also be necessary in order to issue an valid opinion concerning the disease.

Evidence of a substantial reasonable doubt being raised as to the examiner issuing a fully informed opinion includes:

a.) The examiner noted that my medical records did not indicate I had any unique medical conditions that are associated with asbestos. However, he failed to mention my Interstitial Lung Disease that was indicated in x-rays taken at xxx Medical Center and xxx Hospital in 2000, and confirmed with a diagnosis in a pathology report at xxx Hospital in September 2000. Interstitial Lung Disease is often linked to asbestos exposure, yet the examiner did not mention it, nor provide rationale, based on sound medical principles, for making a determination that my Interstitial Lung Disease was not a medical condition that is associated with asbestos.

b.) The examiner noted there does not appear to be anything in the medical records to support the presumptive diagnosis of exposure of asbestos.

I did not ask to be granted a presumptive diagnosis of exposure to asbestos. I clearly indicated specific work tasks I did, in specific instances, which exposed me to asbestos working as an electrician in the Air Force. Additionally, my post service medical records clearly indicate asbestos exposure.

Both my treating pulmonary physician and oncologist at xxx discussed my occupational history with me, and indicated in their medical records that it was likely I was exposed to asbestos while working as an electrician in the Air Force.

Written Notes in Chronological Record of Medical Care 10/3/2001 – Dr. xxx(In Medical Records from xxx Air Force Base) states:

“CXR rpt seen > Upper Lobe Scarring & 3 cm Left Lung SPN

Also likely asbestos exposure as electrician 1969 – 1982”

New Patient Note 10/10/2001 – xxx, MD – Oncologist

(In Medical Records from xx Air Force Base) states: “The patient’s past history is somewhat remarkable in that he worked as an electrician in the air force and was exposed to asbestos.”

The Nursing Assessment from xxx Hospital 9/29/2000 also notes under Respiratory system:

· Asbestos exposure

· Lung CA

· Cough

The examiner gave no rationale for disregarding the notations of asbestos exposure in the medical documentation. He did state that the medical records did not indicate any industrial hygiene surveys or show any evidence of being on any unique occupational health surveillance programs. However, he failed to articulate whether these types of programs, in regard to asbestos, were even in effect in the Air Force during the 70’s and early 80’s. As evidence will show that such programs were not in effect at such time – indicating there is a lack of such records, without indicating that the lack is the result of such programs not being in existence at such time, is very misleading, if not uniformed.

Additionally, the examiner stated there was no solid evidence that I was routinely exposed to asbestos. However, he did not articulate whether he was indicating that asbestos exposure would have had to been routine to have played a role in the development of my cancer, the degree of exposure would need to be to be considered routine, and what medical bases support such a decision.

Based on the above mentioned issues, it appears the examiner’s report was either very uninformed or very biased, in that he noted that I had a history of smoking and a pathology report of emphysematous changes, yet he made no notations in the report of the indications of asbestos exposure in my medical records, my diagnosis of Interstitial Lung Disease, or the restrictive patterns in my pulmonary function tests - and gave no medical bases for disregarding these in his opinion.

To make a decision that my lung cancer is secondary to my long term use of cigarettes, while failing to mention any of the evidence of record of asbestos exposure, though noting what evidence was NOT in the record -- occupational health surveillance records which were part of a program initiated AFTER I was no longer an electrician, seems rather flawed.

By not discussing the evidence OF record, the examiner gave no rationale, based on medically sound principles, for the determination that my cancer was secondary to smoking and not related to my in-service asbestos exposure. Nor did it provide a medically sound basis for the determination that I had no apparent residuals from my left lower lobe lobectomy.

As such, the report should be considered inadequate for rating purposes.

[Hoppy]

This is my take on this situation.

I do not recall anybody who filed a claim for asbestosis related cancers on the board. If there is somebody around they would probably have a better understanding of this specific disease than me.

It is better to bring in strong medical evidence in support of your claim rather than argue about the flaws of a previous exam. They will repeat their errors.

I would claim both the inservice condition and any presumptive condition that is applicable. Do not rule out one or the other. If you are seeking service connection of the inservice condition as being related to the current condition then you would need a nexus letter from a doctor/ Do not argue the nexus yourself. Get a doctor to write the letter. The C&P examiner might not have mentioned that you are seeking service connection of the inservice condition beacuse he did not want to tip you off that you need a nexus letter.

If you get the nexus letter then they will have to address this issue. The VA often does not address issues until the veteran brings the issue into the case.

If you are seeking a presumptive condition then you need to show that your current diagnosis is in fact presumed to be secondary to asbestos exposure. You do make mention that one of your diagnoses is associated with asbestos. The VA should have a list of presumptive disorders. The fact that he stated you have no presumptive conditions and ommitted the Interstitial Lung Disease could have been a trick. The VA does not award some types of cases unless you tell them how to apply the medical facts and laws.

There could be two issues. The first issue is service connection. The second issue is the rating of a service connected condition. I am not really familiar with the regs. Maybe Vike or Berta have a different opinion because they know these things. I am going on the terminology. It sounds like an instruction for rating a disability.

It could be the regulation you cited applies to the rating of a service connected disability. That is before that code would be in effect you have to be service connected.

Did this examiner make any reference as to exactally what he thought your current diagnosis was. If not, this would be the big flaw if the VA has a list of presumptive cancers..

ARE YOU SEARCHING BVA DECISION OR JUST CASE LAW. YOU CAN WORD SEARCH THE BVA DECISIONS.

HAVE YOU FOUND ANY CASES IN YOUR RESEARCH WHERE THE SAME DIAGNOSIS YOU HAVE WAS SERVICE CONNECTED FOR ANY REASON. I HAVE TALKED TO VETERANS WHO WERE SERVICE CONNECTED FOR CANCER. IF SO WAS IT PRESUMPTIVE BASED ON EXPOSURE IN THE MILITARY OR DO THE SYMPTOMS HAVE TO DEVELOP WHILE IN THE MILITARY OR ONE YEAR AFTER.

HAVE YOU FOUND ANY CASES WITH YOUR DIAGNOSIS THAT WAS DENIED AND WHAT WAS THE LOGIC ON THOSE.

[Hoppy]

Free,

As Berta mentioned on the other topic the trick is to get them to read your letter.

In the old days of establishing a "well grounded" claim once they made a denial the RO would not even read any letters you sent. The only thing they would read is new medical evidence.

The thing I am afraid of is that since they scheduled the C&P and the cliam was denied they will view your claim in the same light as a claim that is not well grounded and your letters will not even be read until the BVA. The nexus letter is a standard form and it necessary for a claim to service connect a disease that showed symptoms in the military.

I argued for five years. I sent in case numbers of BVA claims that were awarded for my same condition. I sent medical literature about my disease. The claim went nowhere until I got the nexus letter. In the old days, before the VA was required to schedule a C&P when the veteran had a post service diagnosis they did not even respond to my requests to schedule a C&P for five years. VA doctors would not even write nexus letters. It was not until the VA issued a directive in 2000 instructing VA doctors to write nexus letters that they read anything I sent them. Alex told me the claim would go nowhere until I got the nexus letter an he was right. I got the letter and it got me service cionnected 8.5 years after the claim was filed.

[free_spirit_etc]

My husband claimed direct service connection at the get-go (based on the growth rate of the cancer indicating it began in service) The asbestos was the secondary. We are arguing both. The VA dropped the ball on the direct service - and only askd the examiner to issue an opinion on eitology.

Lung cancer is one of the presumptive illnesses with the one year connection.

Good point about the nexus letter and trying to support the calim rather than point out their flaws. Though I think doing both might help - especially at the BVA level.

My take is that if we get a nexus letter AND point out the flaws of the C&P "exam" (that never examined him) my husband might win at the BVA level.

If we point out the flaws of their exam - the BVA might remand it. - whch will just take it up one more level of the spiral.

If we do neither - it will will probably keep going around the same loop.

My husband thinks we have a strong enough case - - and if a new C&P examiner doesn't address the issues we have pointed out - the BVA will remand it. But yeah..that takes time. And with a terminal diagnosis - time is not something we can afford to lose.

I also see the RO gets opinions from university experts - and these are usually not in favor of the veteran. (i.e. they know who to ask for a negaive opinion). The university opinions are usually not well supported.

Oddly enough - many of the cases I have researched that were denied were based on medical opinions of the veterans OWN treating physician.

One said that it was "hard to write" but that she didn't think the cancer had started in service. Other opinions are the VA 'impossible to say" ones.

Now this has concerend me. Why in the world would a vet turn in a report that was AGAINST them?

Does the vet just ask for an opnion and the doctor writes a negative one and sensends it directly to the VA.

Or does the VA notice that you have not turned in a letter in support of your calim from your treating physician - and contact them for an opinion - figuring that they will write a negative one or a wishy washy "can't tell" one in order to deny the claim.

It doesn't make sense that the veteran would obtain an opinion that is not in their favor - and send it in. Yet there are many cases with vets with non supportive letters from the treating physician.

Or is it just that the nonsupporting part is all the BVA lists in their discussion?

At first we thought we could probably get a supporting C&P exam - if the doctor has to address the issues we brought up.

Now I am more inclined to think they will do the wishy washy "can't tell"

Though again, if there are standard growth rates for cancer the examiner SHOULD note why he has determined that THIS cancer is so unusual that the standard growth rates do not apply. Why would it be more likely than not that THIS cancer MAY have doubled at a rate that is not only faster than the typical cancer - but faster than any rate reported for this type of cancer by ANY medical reseach.

I have looked up some placed offering second opinions.

I really wish my husbands treating oncologist would write an opinion - even if the VA does not give it much weight. It still seems it is better to have an opinion in support from the person who treats you - as the lack of such letter can be interpreted as non support.

But his doctor said the VA will do what it wants to and it doesn't matter what anyone else says.

So I thnk our next step is to find someone who WILL write the opinion - and then ask his treating doctor to ask for a referal to THAT doctor - and have THAT doctor indictae in HIS report that the treating doctor has asked for a second opinion.

The we could get the opinion - and still link it to the treating physician - so it won't look like a doctor shopping opinion.

I think we can definately win in the end - it is more a matter of how long the journey will take - and how much time my husband has left to comeplete the journey.

Free

This is my take on this situation.

I do not recall anybody who filed a claim for asbestosis related cancers on the board. If there is somebody around they would probably have a better understanding of this specific disease than me.

It is better to bring in strong medical evidence in support of your claim rather than argue about the flaws of a previous exam. They will repeat their errors.

I would claim both the inservice condition and any presumptive condition that is applicable. Do not rule out one or the other. If you are seeking service connection of the inservice condition as being related to the current condition then you would need a nexus letter from a doctor/ Do not argue the nexus yourself. Get a doctor to write the letter. The C&P examiner might not have mentioned that you are seeking service connection of the inservice condition beacuse he did not want to tip you off that you need a nexus letter.

If you get the nexus letter then they will have to address this issue. The VA often does not address issues until the veteran brings the issue into the case.

If you are seeking a presumptive condition then you need to show that your current diagnosis is in fact presumed to be secondary to asbestos exposure. You do make mention that one of your diagnoses is associated with asbestos. The VA should have a list of presumptive disorders. The fact that he stated you have no presumptive conditions and ommitted the Interstitial Lung Disease could have been a trick. The VA does not award some types of cases unless you tell them how to apply the medical facts and laws.

There could be two issues. The first issue is service connection. The second issue is the rating of a service connected condition. I am not really familiar with the regs. Maybe Vike or Berta have a different opinion because they know these things. I am going on the terminology. It sounds like an instruction for rating a disability.

It could be the regulation you cited applies to the rating of a service connected disability. That is before that code would be in effect you have to be service connected.

Did this examiner make any reference as to exactally what he thought your current diagnosis was. If not, this would be the big flaw if the VA has a list of presumptive cancers..

ARE YOU SEARCHING BVA DECISION OR JUST CASE LAW. YOU CAN WORD SEARCH THE BVA DECISIONS.

HAVE YOU FOUND ANY CASES IN YOUR RESEARCH WHERE THE SAME DIAGNOSIS YOU HAVE WAS SERVICE CONNECTED FOR ANY REASON. I HAVE TALKED TO VETERANS WHO WERE SERVICE CONNECTED FOR CANCER. IF SO WAS IT PRESUMPTIVE BASED ON EXPOSURE IN THE MILITARY OR DO THE SYMPTOMS HAVE TO DEVELOP WHILE IN THE MILITARY OR ONE YEAR AFTER.

HAVE YOU FOUND ANY CASES WITH YOUR DIAGNOSIS THAT WAS DENIED AND WHAT WAS THE LOGIC ON THOSE.

[free_spirit_etc]

Yeah. Actually this letter is probably directed more to the BVA than the RO. The RO MIGHT read it - but if they don't - the BVA shold read it when it finally gets there.

And I was hoping that at the BVA level - they wouldn't give the C&P report much weight if we can show how inadequate it was. Plus for rating purposes - even if he got approved for back pay - since the examiner indicated he had no residuals at that time - he wouldn't even get benefits for that period of time - so I wanted to point out the guy never even SAW him - and that resduals were apparent in the medical records. His PFTS alone would rate him between 30 and 60 percent from the time he ended treatment until his cancer recurred (which should take him back up to 100%).

And no - you can't just STATE a person doesn't have residuals from having part of a lung removed without looking at the PFT reports done by your own hospital the same day. You have to give medical reasons as to why the loss of part of the lung did not cause the reduced PFTs.

And the RO didn't really look at his file. They just repeated what the doctor said.

Most of my husband's SOCs and C&P reports for other claims are very intensive. The report and the SOC on the lung cancer are very brief and don't really address anything.

The examiner even said there was no indication of any respiratory problems on his DISCHARGE PHYSICAL.

The SOC said the examiner indicated there was no evidence of any repiratory problems in his SERVICE MEDICAL RECORDS.

About HALF of his service medical treatments were for respiratory problems. (Upper and lower respiratory tract infections).

I know that would be a "harmless error" as there is no evidence that respiratory infections would cause lung cancer - but when they say "Your claim is denied BECAUSE there is no record of resipratory problems in your service medical records" -- and there ARE significant records of resiratory problems - GRRR

For some reason I don't expect to win at the RO level - even with a nexus letter. But I hope to build a strong enough case that my husband can win at the BVA level, rather than have the case remanded.

Free

Free,

As Berta mentioned on the other topic the trick is to get them to read your letter.

In the old days of establishing a "well grounded" claim once they made a denial the RO would not even read any letters you sent. The only thing they would read is new medical evidence.

The thing I am afraid of is that since they scheduled the C&P and the cliam was denied they will view your claim in the same light as a claim that is not well grounded and your letters will not even be read until the BVA. The nexus letter is a standard form and it necessary for a claim to service connect a disease that showed symptoms in the military.

I argued for five years. I sent in case numbers of BVA claims that were awarded for my same condition. I sent medical literature about my disease. The claim went nowhere until I got the nexus letter. In the old days, before the VA was required to schedule a C&P when the veteran had a post service diagnosis they did not even respond to my requests to schedule a C&P for five years. VA doctors would not even write nexus letters. It was not until the VA issued a directive in 2000 instructing VA doctors to write nexus letters that they read anything I sent them. Alex told me the claim would go nowhere until I got the nexus letter an he was right. I got the letter and it got me service cionnected 8.5 years after the claim was filed.

[Hoppy]

Do not give up on the RO. They do reverse their mistakes when you impress them with the fact that you have doctors supporting you and you know the applicable laws. I argued until I was out of arguments. The VA remained silent and did noting to seek medical evidence on my behalf. Service connection was awarded by the RO after two denials. I got the nexus letter on my own. The nexus letter was sufficient for service connection. I did not have a C&P exam. The problem was that it took me five years to get the nexus letter. I told the RO had they scheduled a C&P the results of the C&P would have been the same as the opinion in the nexus letter.

"My husband thinks we have a strong enough case - - and if a new C&P examiner doesn't address the issues we have pointed out - the BVA will remand it. But yeah..that takes time. And with a terminal diagnosis - time is not something we can afford to lose."

Your case is strong enough to possibly get a remand for another exam. Without a medical nexus it is not likely that that your case is strong enough to win at any level. The fact that you have read the literature and found the holes in their logic does not win cases. Doctors opinions win cases.

How did you determine the expected growth rate of the tumour? Was this in a medical opinion or literature? If it was a medical opinion and it is in writing make sure the RO has this information. If it is in literature get a doctor to make a statement that it applies to your case.

[free_spirit_etc]

Thanks! Have been talking to my husband about the need for the nexus letter - if for nothing else than to speed up the case.

And proactive gives us a bit more control (I hope)

He will talk to the radiation oncologist he went to and see if he would be willing to write a letter.

If not - plan B will be:

Writing to the Armed Forces Institute of Pathology and see if they would be willing to issue us a more likely than not statement. I was VERY encouraged on the doubling time theory when I saw that quite a few cancer cases had been granted based on their opinions (sought by the VA). But their website says their second opinions are $171 minimum (more if they do pathology work). They won't get involved in civil lawsuits - but have issued opinions for the VA (most of them favorable to the veteran). I think we have to go through a doctor (if they are willing to issue an opinion) - but we should be able to get one of the doctors to refer us. Their second opinions are usually the kind where they confirm the actual diagnosis - but it won''t hurt to ask for an onset opinion.

We considered asking the RO to seek their opinion - but that involves the risk of the opinion NOT supporting us and the VA getting it first.

Plan C

Asking each of his doctors to refer him to a doctor who WILL issue an opinion.

Plan D

Finding a doctor who will issue an opinion and then tell his doctor we would like a referal for a second (or first as the case may be) opinion.

Plan E

Same as plan D - but lacking the referal from a treating physician.

Plan F

I will go to medical school and should be qualified to issue an opinion myself by the time it reaches the BVA :)

My husband's pulmonolgist on base told him that the growth rate was 6 months doubling time for adnocarcinoma. He also wrote it all down on a piec of paper -- about growth rates and doubling times.

(how a cancer has to double 35 times to reach 3.1 cm)

My husband explained this with his claim and submitted the handwritten note from the doctor. I am sure the note does not look like an official opinion. Too bad they probably wouldn't accept it as a more honest opinion because it was written to educate the patient about his disease. B)

In the evidence we recently submitted - we sent articles which supported this. Each article gace the typical doubling time for pulmonary adenocarcinoma at 180 days. This included a SEERS web based training site from the National Cancer Institute. (and the NCI site says "The SEER Program is considered the standard for quality among cancer registries around the world.") We also sent several journal articles stating the same thing -- and sites showing the same thing is taught at Universities.

And we did get a letter from his oncolgist which states what kind of cancer he has - the stage - and that the typical doubling rate is 180 days. (he was hestitant to issue an "opinion" because he says they can only state facts and the VA does whatever it wants anyway. - but at least we got him to write the FACT on the doubling time for us. He just didn't do the more likely than not.

And we even connected the dots for them with articles that give them the dynamics of the growth rate.

from another article:

"For example, at a constant doubling time of 180 days, it takes about 2.3 years for a tumor to grow from a diameter of 1.0 cm to 3.0 cm. Thus, assuming no additional benefit of earlier detection, a patient should live about 2.3 years longer when the tumor is diagnosed at a diameter of 1.0 cm vs 3.0 cm.”

--------so – if it takes 2.3 years for the typical adenocarcinoma to grow from 1 cm to 3 cm – and it has already doubled 30 times to reach 1 cm (35 to reach 3 cm) – how likely is it that it grew to 3.1 cm between retirement (1998) and detection (2000)?

But we DO have written support from TWO of his doctors on the doubling time. (one in an official letter and one in a handwritten note) And we do have literature that supports that - even from the National Cancer Institute. and we have all kinds of literature that builds the case step by step.

We didn't just send in a bunch of articles - we built the case step by step and connected the dots -- and we have several articles to support EACH point.

(And actually quite a few of the points we sent were the same information the Armed Forces Institute of Pathology used in their opinions in other cases ---how many doubling it takes to reach a certain size, etc. They used pretty much the same process we did -- except they applied it to different types of cancer (based on the case) and they didn't have to build such a strong case because they are the Armed Forces Institute of Pathology -- and we are not - lol

So -- if we can get a letter from a doctor that even gives us the more likely than not statement --and a tad bit of slow growing stuff -- we should have some very strong supporting evidence to put around it.

I think it would be hard to deny SC - if a doctor will make that statement. And we have the doubling times verified by a doctor's letter and another doctor's handwritten note we have already submitted -- and lots of medical research submitted that can strengthen even a semi-weak nexus letter.

At least I hope so. And at this point -I am kind of steering away from wanting them to seek medical evidence on my husband's behalf.

Chances are that they will get a C&P guy that will pull one of those "you never know about cancer -- it is different from case to case -

We can argue that with the fact that there ARE medically established doubling times --and chances are my husband is not that ONE RARE case that defies medical logic (at least it is more likely than not that he woudn't be B)

But still hard to argue with what the DOCTOR said..I know

Or he might get one of their college professors from Idaho who say ignorant things like "the medical community considers cancer onset to be when it is first detected" B) --and uses 1956 journal articles to support their points.

It's not that I have anything against college professors. Actually I teach college myself -- but am not a professor (an Instructor -- smaller offices :o - no benefits :P --but I have read some of their opinions in cancer cases. (this case was so complex that we contacted a generic medical expert from a college that no one has heard of who said.........."

So today - I threw out some suggestions to my husband -- to work a plan to get Dr. Nexus -- or to go hang out at the local medical schools (pretty reputable ones even) until he finds a professor who wold be willing to write him an opinion. He picked the doctor.

Actually I thought the professor idea was a GREAT one. After lecturing a few weeks they really appreciate finding someone who really wants to hear what they think... :)

The big thing is convincing them that it isn't a lawsuit --and they won't have to testify in court.

Free (hoping to be probative)

Do not give up on the RO. They do reverse their mistakes when you impress them with the fact that you have doctors supporting you and you know the applicable laws. I argued until I was out of arguments. The VA remained silent and did noting to seek medical evidence on my behalf. Service connection was awarded by the RO after two denials. I got the nexus letter on my own. The nexus letter was sufficient for service connection. I did not have a C&P exam. The problem was that it took me five years to get the nexus letter. I told the RO had they scheduled a C&P the results of the C&P would have been the same as the opinion in the nexus letter.

"My husband thinks we have a strong enough case - - and if a new C&P examiner doesn't address the issues we have pointed out - the BVA will remand it. But yeah..that takes time. And with a terminal diagnosis - time is not something we can afford to lose."

Your case is strong enough to possibly get a remand for another exam. Without a medical nexus it is not likely that that your case is strong enough to win at any level. The fact that you have read the literature and found the holes in their logic does not win cases. Doctors opinions win cases.

How did you determine the expected growth rate of the tumour? Was this in a medical opinion or literature? If it was a medical opinion and it is in writing make sure the RO has this information. If it is in literature get a doctor to make a statement that it applies to your case.