cervical strain Question On What To Do Next

[tsowen]

Recently I filed a claim for:

Claim Received: 03/06/2013

Claim Type: Compensation

Claim Closed: 02/01/2014

Contentions: Thoracic strain with lumbar facet arthropathy L5-S1 (Increase), cervical strain (claimed as tendonitis of neck) (Increase), PTSD- personal trauma w/anxiety d/o and panic attacks (New), Pinfueculitis, bilateral eye (New), VBMS (New), Right ankle, stable joint, aterior talodibulat chronic strain (Increase)

My files are routed through the Houston Regional Office. During the QTC exam the Doctor only filled out the questioner and gave me an x-ray of my neck and back, no physical exam was conducted on either. My back was changed to thoracic strain with lumbar facet arthropathy, L5-S1 with IVDS and radiculopathy and my neck is still listed as a cervical strain and I was denied for increase and still I am rated at 10% for both ratings and the Doctor for the QTC verbally told me that both conditions has gotten worse in his medical opinion but as I stated no physical exam, range of motion or anything was conducted, just the questioner and an x-ray which I already had when I was previously awarded 10% for both service connected injuries, where a range of motion was conducted during those two exams. On my claim I also claimed two new conditions one for pinguecula in both eyes and PTSD and did not have a C&P for either. Both of those claims were also denied. I had a separate C&P exam conducted by QTC for the Right ankle, stable joint, aterior talodibulat chronic strain (Increase) and the Doctor for this exam was pretty confused and asking my rudely why I thought my condition had gotten worse and what was worse about it when I had already filled out the questioner provided by QTC for this exam which he had in front of him. My ankle recently rolled on me prior to the exam so during the exam it was swollen and he kept asking me why was my leg shaking when trying to do the range of motion test, and was I nervous which was causing my leg to shake. I told the examiner that I was in pain and trying my best to do the resistance test. This claim as well was denied so I was denied for all 5 claims. Both QTC exams one for the neck and back and the other for my right ankle were all conducted in the same QTC facility. So what should I do next? Should I file an appeal, reopen the case and see my Primary Care Physician and have him conduct a C&P exam for my neck and back? My neck is the main concern where I always have to pop it to relive the tension.

Edited February 3, 2014 by tsowen

[71M10]

All of my C&P's have been conducted at a VAMC and I have had access to the Exam, with QTC this is probably not the case.

When I know there is a discrepancy between what the Dr. Did and what is on the exam I send in a letter (return receipt requested) specifically addressing the factually incorrect information. Example: On one C&P the doctor listed three measured range of motions on the exam form, but I know for a fact I only performed the movement twice, or they listed Range of Motion testing that was not done. They also have indicated answers to questions I was not asked (but I think there is a default answer- not intentional act by doctor). I have gotten a couple of new exams that way and I seem to be doing OK with that strategy. If QTC has done them, unless you RO provides you a copy (when requested, some have refused) you will need to wait it out for the decision and then NOD and request a copy of your C-file to include all medical exams and records.

I do not see how a proper exam (for rating purposes) for neck or back issues could have been completed without ROM testing.

Since they indicate your decision was made 2/1, post the specific reasons and basis to the forum and more specific help or suggestions can be offered(be sure to exclude SSN's birthdates full names ect.).

Welcome and thank you for your service!

[Navy04]

I had my Physical exam with SSA last Saturday, and because of my Metal braces on both Knees and Back, the DR did not measure my ROM on either. He just did the bend your toes and checked the strength of my hands and that's it. I told the Doc if he wanted to remove braces and do the ROMs, but he said their was no need. So I don't know if that was good or bad.

[tsowen]

Thanks for the advice, I should have the brown envelope today and will post the reasons for the denial.

[Berta]

As ZIM10 suggested, maybe the same type of letter would work for you.But then again QTC is different from a regular VAMC C & P exam.

If we can see the decision we can help more.

“On my claim I also claimed two new conditions one for pinguecula in both eyes and PTSD and did not have a C&P for either. “

I dont know why they didnt give you a C & P for these...maybe they deferred the claims to await a C & P to be scheduled??

Do you have diagnosis of these conditions in your med recs, and treatment records as well?

The rating criteria for bilateral pinguecula is within this BVA decision:

http://www.index.va.gov/search/va/view.jsp?FV=http://www.va.gov/vetapp13/Files3/1328074.txt

The criteria for all PTSD claims filed after the 2010 regs have come out are within our PTSD forum here. I will bump them up there for you.

Both the eye condition and the PTSD will need an inservice nexus, which VA will concede in some cases, as explained in the PTSD forum.

Navy04 , I am thinking he didn't need to do a ROM due to the metal braces.

Then again there are appeal rights with SSA decisions. And also a Reconsideration format.

I wear sport braces with the hard plastic splints in them.(severe bilateral pronation)

I think those would require a ROM but not metal braces.

[Navy04]

Berta,

The braces for my Knees and back are metal, so I hope you are right. I just hope to find out my SSDI decision soon. My FDC is finally moving. Waco RO requested that the VAs fill out DBQs on my conditions I submitted for increases. I hear that the ROs are requesting that the VAs fill out DBQs, since our treatments are inhouse. Do you think the VA will use this info since I am well documented in current treatment with the VA, or will the VA make me do C&Ps?

[tsowen]

Berta,

For the PTSD and the pinguecula I do have treatment records from my civilian doctor, the only issue I could see would be the service connection for the pinguecula, which I tied it into being Infantry and being deployed to harsh desert conditions without proper eye protection. When I submitted my claim I filled out the forms for the release of my civilian records.

On a different note for sciatica in both right and left leg would I list that as a secondary to my thoracic strain with lumbar facet arthropathy, L5-S1 with IVDS and radiculopathy?