Dm Ii And Vascular Disease

[harleyman]

Does anyone have referenes or experience in getting vascular disease of the lower limbs service connected as secondary to DM II?

Veteran is s/c for DMII and PN with loss of use of one of the lower extremity ( 2 K awards one for loss and the other for ED),and also s/c for IHD. But recent claim for DVT (blood clot and infection in lower leg secondary to DMII ,VA has denied stating the leg condition is not related to the DMII.

Might the veteran get the DVT (clot and or infection)s/c as secondary to IHD?

Thanks!

Edited July 27, 2013 by harleyman

[harleyman]

Well we got the decision, a denial as we expected. I thought it would be just from what the exainer DIDN'T do at the exam. However, the decision I find is rather interesting.

It says:

medical description

peripheral vascular disease/ peripheral arthey disease of both legs

Decision

Service connection for peripheral vasculat disease/peripheral artery disease of both legs is denied

EVIDENCE

curent claim, dated January 16, 2013

VCAA letter dated 4/18/13

Treatmet records from VAMC from 9/1009 though 9/5/2013

VA Form 21-526EZ Veteran's FDC claim submitted by POA, dated August 28, 2013

Reason for Decision

Service connection may be granted for a disability which began in military service or was caused by some event or experience in sevice. Service connection for peripheral vascular disease/peripheral artery disease of both legs is denied because the medical evidence of records fails to show that this disability has been clinically diagnosed.

I find this very interesting for a few reasons.

1. The claim was opened by the Veteran over the phone and was not opened by the VSO's ( so that is an untruth) and the Veteran did not file a 526EZ FDC claim

2. The Veteran claimed the conditions due to his DMII ( this was not addressed in the type of claim nor in the decision, there is no evidence of the VA even considering this condition as secondary)

3. The Veteran went to the C and P examination. They did not base their decision on the exam findings as they did not list the exam as EVIDENCE. So the Veteran really needs to get a copy of the exam so we can see what the examiner had to say. The Veteran told the examiner he had an infection due to his foot ulcer caused by his DMII and not being able to feel his feet, and also told him he did not have a DVT as indicated by the VA records, Obviously the examiner did not give the VA what they wanted or they felt they did not need to reference the exam. (that is a very unusual situation) frankly I don't even know if I have actually seen an exam be omitted from the decision like this before). I don't know if that was intensional or in error.

I would like to ask how all of you how you think we should proceed with this claim, we are open to ideas. Of course, we would like to keep the expenses down if possible.-- Harleyman

Edited September 22, 2013 by harleyman

[Berta]

Odd... is the VA actually saying the VA does not have the medical ability to diagnose this?

And the lack of mentioning the C & P as evidence is really strange.I have never seen anything like that before.

The first time PAD showed up as a diagnose of my husband ( he had lower leg extremity loss due to a 1151 stroke) was within an IMO I got from Dr. Bash, for my DMII AO death claim.….

I never claimed it. Maybe I should. I forget how they actually rated his extremities.

PAD is obviously from atherosclerosis, a known by product of DMII and as this article states, can increase one's risk to IHD, TIAs or stroke.

http://www.nhlbi.nih.gov/health/health-topics/topics/pad/

I guess the VA C & P doc never saw all those commercials in the past years on TV describing PAD.And I guess the VA C & P doc( if it was a real doc) had no knowledge of Endocrinology.

Maybe VA thinks it would cost too much money to properly diagnose this vet with PAD:

http://www.nhlbi.nih.gov/health/health-topics/topics/pad/diagnosis.html

PAD is a disease of the arteries and PN is a disease of the nerves and the VA MUST rate them separately.

“Entitlement to service connection for peripheral neuropathy of lower extremities is granted.

Entitlement to service connection for peripheral arterial disease of the lower extremities is granted.”

http://www.index.va.gov/search/va/view.jsp?FV=http://www.va.gov/vetapp12/Files1/1202154.txt

Also in this case it states:

“The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006).
and:
“In support of his claims, the Veteran, who has a medical background and is a licensed nutritionist, has provided numerous documents, including internet articles and medical literature concerning the negative effects of chlorine ingestion.

In a November 2008 statement, T. H., M.D., PhD, a nephrologist, opined that it was possible that the Veteran's metabolic derangements may be due to exposure to heavily chlorinated water.”
also among other conditions BVA awarded

Entitlement to service connection for type II diabetes mellitus is granted.
Te veteran served in Korea but did not fall, as far as I can tell under the AO presumtives regarding the swath of land near the DMZ. Hios claim seemed to rest solely on metabolic deragements due to the water exposure.

Havent had time to read this all well and I think your vet would have an easier time proving the etiology of his DMII as the cause of his PN and PAD then this vet.
Also the IHD if nor SCed already,in your case, could be found as secondary to the PAD. (or to the DMII)

I suggest to try to get that C & P but the vet could use the commercial itself on PAD to satisfy this clause in the US Court of Appeals Fed Circuit decision above:

"Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006)."

Anyone who saw that commercial (maybe it is on Utube) could identify symptoms they had that could be diagnosed as PAD.

I get leg fatigue from a pronation problem but I sure asked my doctor to rule out PAD and she did,based on my med history and no etiology.

I will try to find that commercial on line if I can.

There is so much good med info from good sources on the net, that maybe, just via printouts, this vet could get a proper diagnosis and rating.for the PAD.

[harleyman]

Well finally got the VA examination and the Medical Opinion for this case. It is eye opening as the examiner clearly missed the whole issue of the VA never confirming htier diagnosis. so here is the actual exam findings and the the examiner's opinion, I am still wondering why the VA did not list this as medical evidence but only stated there was no diagnosis of vascular disease

Artery and Vein Conditions

(Vascular Diseases including Varicose Veins)

Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXXXXXX

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to prepare the DBQ and such an examination will likely provide no

additional relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VA records

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

1. Diagnosis

------------

Does the Veteran now have or has he/she ever had a vascular disease

(arterial or venous)?

[X] Yes [ ] No

Diagnosis #1: Deep Vein Thrombosis, Left Leg

ICD code(s): 453.40

Date of diagnosis: 2012

2. Medical history

------------------

a. Describe the cause/onset of the Veteran's current vascular condition(s)

(brief summary)

The veteran's records indicate that he was diagnosed with a DVT inthe

left leg. However, the veteran denies that he had a DVT and states he

was misdiagnosed. He states he was eventually treated for cellulitis in

the left leg after it "burst open." He was admitted to the

hospital and underwent several surgeries for debridment of the left calf and left

knee as well as the left thigh. He states he was treated with IV

antibiotics and is currently taking PO antibiotics. He vehemently

denies he had a DVT even when shown ultrasound reports indicting a DVT

in the popliteal vein of the left leg. He was initially treated with

heparin and then coumadin. He states he feels his symptoms were

related to the cellulitis and not a DVT. He states he still has swelling of

the left leg and firmess of the left leg worse in the calf. He is

currently using a motorized scooter and a cane to get around. He denies a

diagnosis of peripheral vascular disease, stating that he has diabetic

peripheral neuropathy with symptoms in both feet.

b. Type of vascular disease condition: (Check all that apply)

No response provided.

Section I: Varicose veins and/or post-phlebitic syndrome

--------------------------------------------------------

Not Applicable

Section II: Peripheral vascular disease, aneurysm of any large artery (other

than aorta), arteriosclerosis obliterans or thrombo-angiitis

obliterans (Buerger's Disease)

----------------------------------------------------------------------------

Not Applicable

Section III: Aortic aneurysm

----------------------------

Not Applicable

Section IV: Aneurysm of a small artery

--------------------------------------

Not Applicable

Section V: Raynaud's syndrome

-----------------------------

Not Applicable

Section VI: Arteriovenous (AV) fistula, angioneurotic edema, or erythromelalgia

-------------------------------------------------------------------------------

Not Applicable

Section VII: Miscellaneous Issues

---------------------------------

1. Amputations

--------------

Has the Veteran had an amputation of an extremity due to a vascular condition?

[ ] Yes [X] No

2. Assistive devices

--------------------

a. Does the Veteran use any assistive device(s) as a normal mode of

locomotion, although occasional locomotion by other methods may be possible?

[X] Yes [ ] No

If yes, identify assistive device(s) used (check all that apply and

indicate frequency):

Assistive device: Frequency of use:

----------------- -----------------

[X] Cane(s) [ ] Occasional [X] Regular [ ] Constant

[X] Other: Moterized scooter

[ ] Occasional [X] Regular [ ] Constant

b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:

Cane and scooter used for weakness and left leg pain.

3. Remaining effective function of the extremities

--------------------------------------------------

Due to a vascular condition, is there functional impairment of an extremity

such that no effective function remains other than that which would be

equally well served by an amputation with prosthesis? (Functions of the

upper extremity include grasping, manipulation, etc., while functions for the

lower extremity include balance and propulsion, etc.)

[ ] Yes, functioning is so diminished that amputation with prosthesis would

equally serve the Veteran.

[X] No

4. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

-----------------------------------------------------------------------

a. Does the Veteran have any scars (surgical or otherwise) related to any

conditions or to the treatment of any conditions listed in the Diagnosis

section above?

[ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms related to the conditions

listed in the Diagnosis section above?

[X] Yes [ ] No

If yes, describe (brief summary):

The veteran's right leg has 1+ pitting edema. The veteran's

left leg has less than 1+ pitting edema with swelling and firmness noted to the

left calf. No erythema or skin discoloration is noted. Dressing covers a

surgical scar in the left calf and there is a well healed non-tender

surgical scar over the anterior left knee.

5. Diagnostic testing

---------------------

a. Has ankle/brachial index testing been performed?

[ ] Yes [X] No [ ] Unable to perform, provide reason:

b. Are there any other significant diagnostic test findings and/or results?

[X] Yes [ ] No

If yes, provide type of test or procedure, date and results (brief

summary):

Ultrasound of left lower extremity(12/19/12) Parially occlusive

thrombus, left popliteal vein.

Exam Date/Time:

12/06/2012 11:34

Procedure Name:

ULTRASOUND VEINS, LT LOWER EXT (DUPLEX)

Reason for Study:

check for DVT

Clinical History:

check for DVT

Impression:

Findings suspicious for partial occlusion of the distal superficial

femoral vein and popliteal veins. This is nonspecific, but could represent

acute or chronic deep venous thrombosis. Clinical correlation is suggested.

Report:

EXAM: Left lower extremity venous Doppler, 12/6/2012

HISTORY: rule out DVT

COMPARISON: None

TECHNIQUE: Real-time grayscale as well as limited color and Doppler

ultrasound evaluation of the corresponding veins was obtained.

FINDINGS: The left common femoral, superficial femoral, and

popliteal veins were interrogated. In the distal superficial femoral vein and

popliteal veins, there is mild eccentric echogenicity along the vessel walls

and incomplete compressibility. Although vessels remain grossly patent,

there is suggestion of minimal eccentric filling defect on color flow

imaging.

Dr. XXXXXXXX was notified at 12: 19 hours on 12/6/2012.

Facility:

XXXXXXXXXXXXXXX

6. Functional impact

--------------------

Does the Veteran's vascular condition(s) impact his or her ability to

work?

[ ] Yes [X] No

7. Remarks, if any:

-------------------

The veteran states he did not have a DVT but had cellulitis of the left

leg. He had surgery

for the debridement of the left leg secondary to the cellulitis. He

denies

any symptoms

related to the DVTs found on VA and private ultrasounds and for which he

was treated with

heparin and coumadin.

The veteran claims the cellulitis was due to his diabetes.

Medical Opinion 1

Disability Benefits Questionnaire

Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXXXXX

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because the existing medical evidence provided sufficient information on which

to prepare the DBQ and such an examination will likely provide no

additional relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VA records

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

Your patient is applying to the U.S. Department of Veterans Affairs (VA) for

disability benefits. VA will consider the information you provide on this

questionnaire as part of their evaluation in processing the Veteran's

claim.

1. Definitions

--------------

Aggravation of preexisting nonservice-connected disabilities.

-------------------------------------------------------------

A preexisting injury or disease will be considered to have been aggravated

by active military, naval, or air service, where there is an increase in

disability during such service, unless there is a specific finding that the

increase in disability is due to the natural progress of the disease.

Aggravation of nonservice-connected disabilities.

-------------------------------------------------

Any increase in severity of a nonservice-connected disease or injury that is

proximately due to or the result of a service-connected disease or injury,

and not due to the natural progress of the nonservice-connected disease,

will be service connected.

2. Restatement of requested opinion

-----------------------------------

a. Insert requested opinion from general remarks:

Is the veteran's peripheral vascular disease proximately due to

service connected diabetes, hypertension or coronary artery disease?

b. Indicate type of exam for which opinion has been requested (e.g. Skin

Diseases):

Artery and Vein

3. Medical opinion for direct service connection

------------------------------------------------

Choose the statement that most closely approximates the etiology of the

claimed condition.

a. [ ] The claimed condition was at least as likely as not (50 percent or

greater probability) incurred in or caused by the claimed in-service

injury, event, or illness. Provide rationale in section c.

b. [ ] The claimed condition was less likely than not (less than 50 percent

probability) incurred in or caused by the claimed in-service injury,

event, or illness. Provide rationale in section c.

c. Rationale:

4. Medical opinion for secondary service connection

---------------------------------------------------

a. [ ] The claimed condition is at least as likely as not (50 percent or

greater probability) proximately due to or the result of the

Veteran's

service connected condition. Provide rationale in section c.

b. [X] The claimed condition is less likely than not (less than 50 percent

probability) proximately due to or the result of the Veteran's

service connected condition. Provide rationale in section c.

c. Rationale: The veteran's medical records indicate he had a DVT in

the left leg. The veteran vehemently denies he had a DVT and

states he was misdiagnosed. He states the left leg problem

wasdue to cellulitis which was treated with hospitalization,

surgery and IV antibiotics. He claims the cellulitis was due

to his diabetes.

There is no indication in the medical literature that

diabetes is a risk factor for cellulitis. It is also not a risk factor

for a DVT which is due to disruption of normal blood flow in

a vein or to other factors such as clotting factors. Therefore,

based on a review of the veteran's medical history, a

review of medical literature and clinical experience and expertise,

the veteran's peripheral vascular disease(or cellultis)

is less likely than not proximately due to service connected

diabetes, hypertension or coronary artery disease.

5. Medical opinion for aggravation of a condition that existed prior to

service

-------------------------------------------------------------------------------

a. [ ] The claimed condition, which clearly and unmistakably existed prior

to service, was aggravated beyond its natural progression by an

in-service injury, event, or illness. Provide rationale in section

c.

b. [ ] The claimed condition, which clearly and unmistakably existed prior

to service, was clearly and unmistakably not aggravated beyond its

natural progression by an in-service injury, event, or illness.

Provide rationale in section c.

c. Rationale:

6. Medical opinion for aggravation of a nonservice connected condition by a

service connected condition

---------------------------------------------------------------------------

a. Can you determine a baseline level of severity of (claimed

condition/diagnosis) based upon medical evidence available prior to

aggravation or the earliest medical evidence following aggravation by

(service connected condition)?

[ ] Yes [ ] No

If "Yes" to question 6a, answer the following:

i. Describe the baseline level of severity of (claimed

condition/diagnosis) based upon medical evidence available prior

to

aggravation or the earliest medical evidence following aggravation

by (service connected condition):

ii. Provide the date and nature of the medical evidence used to

provide

the baseline:

iii. Is the current severity of the (claimed condition/diagnosis)

greater than the baseline?

[ ] Yes [ ] No

If yes, was the Veteran's (claimed condition/diagnosis)

at

least as likely as not aggravated beyond its natural

progression by (insert "service connected

condition")?

[ ] Yes (provide rationale in section b.)

[ ] No (provide rationale in section b.)

If "No" to question 6a, answer the following:

i. Provide rationale as to why a baseline cannot be established (e.g.

medical evidence is not sufficient to support a determination of a

baseline level of severity):

ii. Regardless of an established baseline, was the Veteran's

(claimed

condition/diagnosis) at least as likely as not aggravated beyond

its natural progression by (insert "service connected

condition")?

[ ] Yes (provide rationale in section b.)

[ ] No (provide rationale in section b.)

b. Provide rationale:

7. Opinion regarding conflicting medical evidence

-------------------------------------------------

I have reviewed the conflicting medical evidence and am providing the

following opinion:

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's application.

So I found a really strong artical about PAD and diabetes, IHD/CAD, and hypertension all if which the veteran has service connection for. After the horrific treatment from VA and then reading this artical on PAD, I am firmly convinced the Veteran was mis-diagnosed and left to worsen from the wound on his toe from diabetes and the subsequent infection. I will be encouraging him to file an 1151 claim, as well as a private mal-practice claim against the other hosptital who admitted him and then treated him in emergency following the VA lead on an incorrect diagnosis.

http://care.diabetesjournals.org/content/26/12/3333.long

Berta and free_spirit you guys are really good at the rationale stuff for appeals and IMO's:

If you are so inclined, after reading the article at this link it talks about what happens to the diabetic who is not properly diagnosed and it is exactly what I was told occurred, please disect for any fighting points you may see for an IMO or appeal or any of the other aspects in this case you think need to pay specific attention to. I appreciate all you do . Thanks- Harleyman

Oh and the Veteran has PN 2nd to DMII in addition to the IHD/CAD/ HTN/

Edited October 6, 2013 by harleyman

[free_spirit_etc]

"There is no indication in the medical literature that

diabetes is a risk factor for cellulitis. "

It is interesting that Mayo says diabetes IS a risk factor: (Maybe the C&P examiner knows more than the doctors at Mayo Clinic??)

http://www.mayoclinic.com/health/cellulitis/DS00450/DSECTION=risk-factors

Several factors can place you at greater risk of developing cellulitis:

• Known injury. Any cut, fracture, burn or even a scrape increases your risk of cellulitis because the injury gives bacteria an entry point.
• Weakened immune system. Conditions that weaken your immune system leave you more susceptible to infections, such as cellulitis. Conditions that can weaken your immune system include diabetes, chronic leukemias, HIV/AIDS, chronic kidney disease, liver disease and circulation disorders. The use of certain medications, such as corticosteroids, also can weaken your immune system.

Edited October 6, 2013 by free_spirit_etc

[free_spirit_etc]

There should be something that shows that using antibiotics short term actually worsened the condition too. Not just that the infection flared back up when the antibiotics were discontinued - but that the inappropriate use of antibiotics actually caused the infection to worsen. It is why they tell people to continue taking antibiotics even when their symptoms improve - because the infection doesn't just come back - it comes back worse.

[free_spirit_etc]

Is there any way to get the C&P exam declared inadequate and get a new one ordered? Of course that might take awhile, but where the examiner is talking about how the veteran denies having DVT -- even though it was diagnosed is ridiculous.

Did the examiner have a copy of the report from the hospital that said he did NOT have DVT, and was in fact over anti-coagulated?