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Claim Nearing Decision Phase But I'm Concerned

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wpcoder

Question

I began a claim in August 2013, after going to the VAMC for the past 12 years from time to time for what they now call "anxiety and depression". I initially went to the VARO and they initiated a claim for "anxiety due to physical assault in basic training" and "back condition". Only on my second visit to the VARO did they provide me with Form 21-0781 for determining PTSD. The VAMC according to my medical records have never used the term "PTSD" in my file as of yet.

I have since gone to the DAV for representation, thanks in part to the great information on this website. I gave them my buddy statements to submit on my behalf since there was no documentation of the assault at the time.

I am concerned that as of today by file has been moved to the "Preparing for Decision" phase on eBenefits webpage. They estimate my claim to be complete between Jan 2014 - April 2014 - moving the window up one month from last week. That means my claim could be complete in less than six months total time.

I know I should be happy that it's not taking two years to complete, but this is almost too fast, maybe? They did the C&P for my back in October already (and have military documentation of a back condition on active duty), and I was not happy with the results when I read my records. I was unprepared and had not talked to the DAV yet, and didn't realize they rate your range of motion and not whether bending over causes you pain or not.

I have never done a C&P for PTSD or anxiety. Could they be using my medical records and buddy statements and not require a C&P? Or could that still happen?

I'm a bit naive on this whole process. I didn't even know there was such a thing as SC disability unless you got hurt in combat. Any help, thoughts, suggestions would be appreciated. Thanks.

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All you got was 10%. What conditions did you claim and which one was approved for the 10%?

I don't know yet. When I access the award notification on eBenefits it doesn't give me a breakdown. I claimed anxiety and a back condition. I had a GAF score of 50 for anxiety, which should have been called PTSD and that's another mystery as to why they did not. Remember they never gave me a C&P for that, so I'm guessing the 10% was for my back.

I will have to get with my DAV rep if he is in the office next week, or wait and see if a more detailed explanation arrives by mail.

I had proof that both conditions were service-related. But I don't go to the doctor a lot, and they pretty much admitted that they like to see more paperwork. At the same time, a doctor told me that vets seeking a claim tend to go to the doctor more than they need to because they think it helps their claim.

I'll definitely appeal. I was told I could ask for a 'reconsideration' as well. Not sure how that differs from an appeal but I'm sure my rep will explain. I'll get a lawyer if I have to. I can't believe they fast-tracked it through with such a low rating.

I don't even know if they had time to review all the documentation I submitted. There was no way for me to verify on eBenefits that they did.

Edited by wpcoder
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This is the 10 percent rating for spine. Congrats on the partial and good luck on the next step.

http://www.ecfr.gov/cgi-bin/text-idx?SID=4fe61eefb8c314e7f14377d2f1e72d13&node=38:1.0.1.1.5.2.98.26&rgn=div8

The Spine

Rating

General Rating Formula for Diseases and Injuries of the Spine

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

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

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

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

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

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

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

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

5235 Vertebral fracture or dislocation

5236 Sacroiliac injury and weakness

5237 Lumbosacral or cervical strain

5238 Spinal stenosis

5239 Spondylolisthesis or segmental instability

5240 Ankylosing spondylitis

5241 Spinal fusion

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

5243 Intervertebral disc syndrome

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

Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes

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

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

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

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