hypertension Absence Of Evidence=Negative Evidence/va Dr. Shopping

[lotzaspotz]

I suspect we've fallen prey to the VA's well known practice of no news is bad news, and if they don't like one C & P examiner's opinion, just shop for another. Please tell me what you guys think,

My husband underwent surgery in November 1992 to remove a pituitary brain tumor. He medically retired in August 1993 and filed for hypertension (HTN), secondary to the pituitary surgery which is service connected at 60%, because he undergoes hormone replacement therapy (Depo-testosterone by needle every two weeks) and has done so since November 1992. A known by-product from the use of testosterone is hypertension. He has been taking meds for hypertension since 1995, when he was formally diagnosed with HTN, even though there was ample evidence of elevated blood pressure readings prior to his retirement and within one year of that date (August 1993). The VA wants to argue that that the HTN developed due to non-service connected reasons.

He's undergone a number of C & P exams for this condition over the years. The claim has been repeatedly remanded between the Board and the RO. He underwent a C & P exam on 6/26/11, wherein the examiner opined that it was at least as likely as not that HTN was present within one year of military separation and is less likely it was related to the pituitary tumor condition requiring surgery (no rationale as to WHY he reached this conclusion in any clinical sense). The examiner stated that he reviewed the records and there was documentation of elevated blood pressure between August 1993 and April 1995. My husband's records also included blood pressure readings for July 1993, 143/87, December 1994 130/95, February 1995 145/102. However, the first actual diagnosis of HTN was April 17, 1995. That went to the Board who bounced it back to the RO for details. What we now have from a C & P conducted January 15, 2014 states this:

"STRS indicates blood pressure July 1993 143/87 mmHg. This elevated blood pressure does not make the diagnosis of HTN, and STRS do not indicate treatment or diagnosis of a HTN condition, and therefore, given this examiner opined that the chronic hypertension began in May 1994, it is less than likely the hypertension was present in-service, especially since VA rating purposes require the initial diagnosis of HTN to be confirmed by reading taken 2 or more times on at least 3 different days. Review of the veteran's medical record did not show a consistently elevated blood pressure readings to make the hypertension diagnosis while during military service. Therefore, it is less than likely the current HTN occurred during military service, but was diagnosed between May 1994 and September 1994, which was within the first year of after military separation, but not during active military duty."

This opinion offers no rationale regarding why there is no relationship between the use of testosterone in hormone replacement therapy and my husband's HTN. The fact that no one at Wilford Hall where the surgery took place took blood pressure readings two or more times a day for at least three different days is understandable, considering the fact that at that point, we didn't know he had HTN. He was TDRL at Wilford Hall until his retirement date of August 1993. We did notice he started to experience increased blood pressure readings, which led to the VA acknowledging those readings, but not formally diagnosing him with HTN until after the fact in April 1995. That's absence of evidence, but does that equate to negative evidence?

We have yet to read any discussion in either the June 2011 C & P or the one last month that discusses WHY there is no correlation between the HTN and his bi-weekly innoculations of Depo-testosterone. It appears to me that this
C & P is as inadequate as the previous one.

I guess I need to clinically determine just how long it takes HTN to manifest itself after use of Depo-testosterone begins? What the incubation period is?

Thanks for any insight you guys can give. I need help with strategy, thank you.

[Navy04]

As I said in another topic before. I was medically retired from the Navy for Crohn's Disease, yet VA tried to say that it could be due to my Genes, WTH! I definitely know that the VA will always look elsewhere until they get the answer that the VA is looking for to deny us. Sorry to hear of the crap they are putting you thru. It is great to see another supportive Veteran's Wife.

[Vync]

Check with the VA pharmacy and get a copy of the prescription information sheet, unless they gave you one with the prescription. Check the listed side effects. If there are other side effects from the med which cause a SC, be sure to consider filing for them too.

Dig through his med records, old and new, with a fine tooth comb. Be sure to carefully check the 12 month period after he retired. Check every BP reading for anything unusual and point out the increase trend. Remember that the readings for HTN back then were not as strict as they are today. They got tightened a bit a few years ago. Not sure if the VA is using old or new standards.

Were any personal BP logs kept from back then?

Do you or hubby have any any medical background (nurse, doc, etc...)? If so, you could write a buddy letter/statement which would carry a bit more weight. The problem with these is that the VA often "acknowledges", but ignores them.

You might need a good independent medical opinion from an expert doc (cardiologist) to win, but definitely don't give up. Good luck.

[Berta]

“A known by-product from the use of testosterone is hypertension. He has been taking meds for hypertension since 1995, when he was formally diagnosed with HTN, even though there was ample evidence of elevated blood pressure readings prior to his retirement and within one year of that date (August 1993). The VA wants to argue that that the HTN developed due to non-service connected reasons. “

One of my husbands (Army ,2 HDs) had a pituitary brain tumor. I am glad to hear your husband's surgery for that was a success.

“ The VA wants to argue that that the HTN developed due to non-service connected reasons. “

Sure they do.

You will need a strong medical opinion to support this statement:

“ A known by-product from the use of testosterone is hypertension. “ to show that the HTN is secondary to the testosterone meds he takes for the surgery residuals.”

.”He underwent a C & P exam on 6/26/11, wherein the examiner opined that it was at least as likely as not that HTN was present within one year of military separation and is less likely it was related to the pituitary tumor condition requiring surgery (no rationale as to WHY he reached this conclusion in any clinical sense). “

“ The fact that no one at Wilford Hall where the surgery took place took blood pressure readings two or more times a day for at least three different days is understandable, considering the fact that at that point, we didn't know he had HTN. “

Are you sure of that? I assume you have copies of the Wilford med recs.

I am a civilian but the VAMC treated me overnight once for an infection and took quite a few BP readings during my short hospitalization there.

BP readings ,in my experience were always at least daily for when both of my veteran USMC husband's had been hospitalized .

It doesn't have to be 3 readings in the same day, however.

Maybe this will help...... I have a 1151 HBP claim in process.

My evidence came directly from my FTCA case years ago, with a full medical statement on my husband's improperly medicated HBP, from the head of Cardiology VA Central.

I had never claimed it before and it was rated as NSC by VA long ago.There is not time limit for 1151 claims.

I was surprised to realize from the VACO opinion, that they had accessed HBP readings I had not seen in his running hospital chart in his VA med recs, that stemmed from his initial hospitalization in 1992.

But finally I found them as they were filed separately, within the extensive nursing notes.

I was concerned when I couldn't find them because...I can hardly believe this one but it happened.....they had transferred my husband from Bath VA to Syracuse, and a nurse called me up very early one AM ( I live 5 1/2 hours from Syracuse), to get there right away because his BP was so high.

I still had my livestock to feed, and it was really impossible to get there 'right away' and I told the nurse I was not a doctor, so I what did the VA expect me to do when I got there....?????

But to add, in the Cardio review for the FTCA case, the cardio doc had noted that the nurse's notes were more extensive than the charted hospital records.

I would review ALL of his med recs and any nurses notes if I were you.

The VACO cardio doc even quoted a note the Chaplain had put on the chart.... a note that supported one of my FTCA charges.

“We have yet to read any discussion in either the June 2011 C & P or the one last month that discusses WHY there is no correlation between the HTN and his bi-weekly innoculations of Depo-testosterone.”

Did you raise that on appeal and did the VA have any medical evidence at all from you ( even an abstract from a good medical text) that would warrant them to consider the relationship?

“ It appears to me that this
C & P is as inadequate as the previous one.

I guess I need to clinically determine just how long it takes HTN to manifest itself after use of Depo-testosterone begins? What the incubation period is?”

I feel that it will take a strong IMO/IME to 'clinically determine' that the testosterone shots have caused and/or aggravated the HBP.

I didn't have an IMO for my FTCA case and didnt even think of getting one.

When I recall however all the things such as above that led up to the award, I sure know now that an IMO would have saved me the time and trouble of becoming versed in cardio and neuro enough to go toe to toe with the VA docs.I already had a neuro background due to my Army husband's brain tumor but the Marine husband's Stroke and heart problems were beyond that realm of medical knowledge I had.

You can certainly try to fight this yourself as to the medical aspects but when I re opened a different claim in 2003, I made sure I had 3 IMOs, to strongly rebutt the VA's 3 negative medical opinions.

Vync made a great point.

Years ago I was diagnosed with HBP. The med made me sick so I weaned myself off it (I always had low to normal BP all m life) and I talked to my PCP about it.

I have white coat syndrome.Never at VA or my other docs, only at my PCP office sometimes.

And I know exactly why.

I started taking my own HBP readings myself years ago to show my doc.They are always normal and much lower than what she wanted for me to have .....130/85 .......and my EKGs are always normal with no evidence of hypertensive heart disease.

I think everyone should use a home HBP monitor and keep a log.

Edited February 5, 2014 by Berta

[Berta]

To add, was the 6/26/11 C & P exam done for the most recent BVA remand?

And there has been no decision from the BVA since then?????

Can you tell us the Citation number and docket number of the BVA's last remand so that we can read it at the BVA web site ?

[lotzaspotz]

There are two separate sets of appeals under the same BVA docket number, both dated 12/4/13. This is strictly regarding HTN.

Docket no. 94-36 158A.

Thanks for taking a look.

[Berta]

WOW, this sure has a remand history but the 2013 decision that includes the HTN remand is not posted at the BVA web site yet.