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C&p Rebuttal


betrayed

Question

FAXING THIS TO MY VSO IN THE MORNING< ANY FEEDBACK WOULD BE APPRECIATED

Enclosure (1) C&P Exam Report 9/26/06

Enclosure (2) Cervical Spine History

Dear Robert,

On 9/18/2006 I had a C&P Exam conducted at the Detroit VAMC by Doctor XXXXX M.D. My spouse was present for the entire exam. I gave Dr XXXXXX a copy of enclosure (2) which documents the history and associated pain caused by my cervical condition. Dr XXXXX stated he had reviewed my file including MRI reports and the statements of Dr XXXXX and Dr XXXXXX.

Today I received enclosure (1) in the mail. After a review of the report I would like to point out the following items I disagree with.

From the section:

Medical History including current complaints

a. “States Medication seems to help. No side effects.”

Duragesic side effects include fatigue, sweating, weakness and

tiredness. Oxycodone side effects include drowsiness, dizziness, lightheadedness, sweating, and weakness. Both of these medications are narcotics and prevent me from operating a vehicle or place in me in jeopardy of driving under the influence if I were to operate a vehicle.

b. States “no history of flare ups.”

In order for there to be flare ups I would have to be pain free and that never happens.

c. He repeatedly makes the statement “His work is not affected”.

In his opening statement he states, “Has not been employed for the last year and a half.” When in fact I told him I tried delivering pizzas for 12 hours a week for a couple of months but could not handle that.

d. States I am “not taking any medication for the C-Spine and or right arm.”

I am currently prescribed Duragesic 75 mcg/h and Oxycodone for the pain caused by this condition.

e. No History of acute, incapacitating neck pain in the last 12 months.

I am not able to work because of the neck pain, is this not incapacitating? Doctors normally order bed rest to prevent patients from going to work. My Doctors know that I cannot work so there is no reason to order bed rest. Enclosure (2), which was provided to Dr XXXXXX list 18 doctors, visits in 2005 for neck pain, and list 6 doctors visits for neck pain through April of 2006. It also notes I was to have a cervical spinal fusion because of the pain.

f. “He also complains of that sometimes in 1970, he started to experience throbbing pain in his left knee.”

What I stated was in the late 1970s I started having knee problems while stationed in Hawaii. I was not stationed in Hawaii until 1977 or 78.

g. He states “no history of flare ups.”

Prior to that statement he states, “began experiencing right knee pain on prolonged standing and walking.” “Going up and down stairs is difficult due to increased pain.” “Using medication prn, no side effects.” “Activities of daily living are affected.” “Repetitive motion increases the pain without additional loss of motion.”

h. “His left hip is also throbbing with pain at times.” “There is no limitation daily activities.” His work is not affected but his hip is still painful. “No history of flare ups.”

Then he states “Prolonged standing and walking makes him feel week in his left hip.” Again I do not work!

From the section:

Physical Examination

a. He states “there is no evidence of Carpal Tunnel Syndrome.”

Dr XXXXXX’s Letter which Dr XXXXX said he read states an EMG showed evidence of bilateral Carpal Tunnel Syndrome.

b. He states, “There is no crepitation”

Dr XXXXXX’s C&P report of April 8 2005 states, “the patella appeared to track normally bilaterally with crepitus with movement.” My SMR documents plenty of crepitus in my knees.

From the section:

DIAGNOSES

a. “1. Mild cervical spondylosis. 2. Normal both knees without residual of trauma.

3. Normal Left foot. 4. Normal left hip.”

The evidence of record previously submitted oppose the above diagnoses especially that of Mild cervical spondylosis. Mild cervical spondylosis would not warrant prescriptions of Duragesic and Oxycodone, multiple cervical manipulations, approximately 40 doctors visits in the last three years or recommendations of cervical fusion by two neurosurgeons. My SMR document multiple problems and a long history of knee problems with multiple diagnoses of Patellofemoral Pain Syndrome, and Chrondomalacia and regimes of Physical Therapy. X-rays taken at both the Detroit and Ann Arbor VAMC show degenerative changes in my knees and left hip.

b. He states, “There is no evidence of residual strain involving the left hip and left foot. There is no evidence of Incoordination in the right upper extremities. No evidence of bilateral patellofemoral pain syndrome.”

It is quite obvious that Dr XXXXXX did not do a very thorough review of my SMR’s where there is evidence of all of these.

c. The last statement in the report states “No impairment of daily occupational activities.

Again I do not work!

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Jim you need to ask for another C@P exam. This one is not going to do it. you may want to consider an IMO. Call a local Michigan SSD attorney and ask them who they use for Medical Evaluations for the spine and call them ASAP. Take everything with you and get your report from them. ALso print the Spine Exam from the VA website and take it too and have them go by that.

Good Luck Sailor.

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Jim,

Do you have constipation from taking the opiates?

I took a list of side effects and intended effects caused by each of the meds that I take and listed the ones that applied to me, and gave the site refence of where I got the information.

Chronic intractable pain usually has BTP ( break through pain ), if you have BTP list it and how long it lasts, and the severity of them. I have BTP that leaves me incapacitated on the bed, or couch, or where ever I m happen to be fro 30mins to hours and can't do anything.

You haven't mentioned how your pain affects your ability to do routine household chores, and personal hygene, etc. I have chronic intractab;e pain and I am not able to do anything but lay down and wait out the BTP. I may go days without being able to shave, shower, or anything else by myself, my wife has to do ost of it for me if it gets done.

Best to you,

Boondoc

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left and right lateral flexion are zero to 45 degrees, 15

and left and right lateral rotation are zero to 80 degrees. 50

Jim, he is either missing a reading for both of these measurements. There should be 4 unless hs is saying that 15 degrees is both left and right and 50 is both left and right. That totals to 175.

The Va may kick it back because it appears to me it is inadequate.

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Along the same lines, I'm trying to help another vet with his AO claim. This summarizes his C&P and the response I wrote for him. I need criticism from all you educated people - please! I want to help, not hurt him.

Veterans Affairs Regional Office

1301 Clay St., Room 1300N

Oakland, CA 94612-5209

Re: Rolf T. XXXXXX, SSN XXX-XX-6642

C&P exam of 6 SEP 06

Dear Sir or Madam:

This letter is to protest that the C&P examination conducted by VAMC Martinez staff physician Dr. Thomas E. XXXXXX on 6 September 2006 is inadequate for purposes of adjudicating my claim for mycosis fungoides (MF).

A number of assertions made by Dr. XXXXXX are incorrect. Dr. XXXXXX had no medical information on my condition – no C-file, no lab studies, no progress notes, no clinical diagnoses – nothing! (The claimant has no knowledge whether the RVSR at the Oakland RO furnished an exam guide and questions to be resolved or not – the so-called “blue sheet”.)

I furnished Dr. XXXXXXX with my copies of the Compensation and Pension Examination guide for Lymphatic Disorders, relevant Consult Requests, and Progress Notes from VAMC San Francisco, along with write-ups of medical studies relevant to visual diagnosis of mycosis fungoides and application of the gene rearrangement studies to patch stage MF.

In order of presentation in the C&P Progress Notes, here are the important errors in Dr. XXXXXX’s history, exam and assessment:

HISTORY

The “Doctor” YYYYYYYY mentioned herein is actually Nurse Practitioner YYYYYYY. My consult was to the VAMC San Francisco Dermatology Department and I actually see a number of other dermatology clinicians in addition to Mr. YYYYYYYY. Mr. YYYYYYY acts as the “physician of record” for some of my treatment encounters, but he also consults M.D.s on diagnosis and treatments and I see other medical staff when Mr. YYYYYYYY is unavailable.

I never stated that I felt my “condition is getting somewhat better.” That question was never asked and I haven’t noticed it getting better. That’s why the UV treatment will commence now.

PUVA is a recognized treatment for mycosis fungoides in the early stages.

“He had a T-cell study which was performed 07/27/06 which did not support the diagnosis of mycosis fungoides” (true, but misleading – see Br J Dermatol, 2005 Aug. 153(2):368-71 below)

“and therefore the acting diagnosis is psoriasis. . . . . .” (and mycosis fungoides – see VAMC Ft. Miley Progress Note of 27 JUL 06 titled “Dermatology Clinic UVL Pretreatment Assessment Note”; reference Item b) – Diagnosis).

Rolf T. XXXXXX SSN: XXX-XX-6642 Page -2-

“There is no working diagnosis at this point . . . .” A working diagnosis is based on a clinical impression and the treatment regimen is suited to both psoriasis and early stage MF. Progress Notes consistently mention MF history and consider it in treatment. There is no specific diagnosis of MF as yet and a C&P exam that included punch and slice biopsies would produce a result with probative value, rather than just a recap of data already clinically considered. It is mainly the lack of any consideration of relevant lab studies by the examiner that causes me to protest this C&P exam. Various Progress Notes confirm general clinical MF diagnosis agreement among dermatology staff and visiting medical personnel who had reviewed the punch and slice biopsy results.

I have no protest for Dr. XXXXXXX’s exam or assessment entries as the inadequacy of the C&P exam could produce no other result.

I have copied the handout given Dr. XXXXXXX relevant to specific diagnosis and the probative value of the Stanford Lab study and insert it below:

“THE PROBLEM:

From the PubMed of the National Institutes of Health:

J Am Acad Dermatol. 2002 Dec;47(6):914-8.

Mycosis fungoides: the great imitator.

Zackheim HS, McCalmont TH.

Department of Dermatology, University of California, San Francisco, USA.

A considerable number of reports have documented mycosis fungoides (MF) mimicking other dermatoses, but a comprehensive review has not been published. Our aim was to comprehensively review reports of various dermatoses simulated by MF. Additionally, 2 cases in which MF simulated diseases not previously documented (psoriasis and erythema annulare centrifugum) are presented. A literature search of all case reports of MF cited in the MEDLINE database from 1966 through 2000 plus those in one of the author's (H. Z.) files was performed. A total of 23 reported cases of dermatoses mimicked by MF were found. With the additional 2 dermatoses now presented, this yields a total of at least 25 diseases that can be simulated by MF. In view of the considerable number of dermatoses simulated by MF, the term “the great imitator” is appropriate for MF.

= = = = = = = = = = = = = = = = = =

Rolf T. XXXXXX SSN: XXX-XX-6642 Page -3-

THE STANFORD LAB ASSAY OF CLONALITY IS INDETERMINATE:

Br J Dermatol. 2005 Aug;153(2):368-71

The usefulness of clonality for the detection of cases clinically and/or histopathologically not recognized as cutaneous T-cell lymphoma.

• Alessi E,

• Coggi A,

• Venegoni L,

• Merlo V,

• Gianotti R.

Institute of Dermatological Sciences, University of Milan, IRCCS Ospedale Maggiore, Via Pace 9, 20122 Milan, Italy. elvio.alessi@unimi.it

BACKGROUND: The determination of clonality has proven to be a useful adjunct to the diagnosis of cutaneous lymphocytic infiltrates. It is considered particularly helpful for the distinction of mycosis fungoides (MF) and inflammatory dermatoses. OBJECTIVES: To verify the sensitivity of the polymerase chain reaction (PCR)-heteroduplex analysis of T-cell receptor gamma-chain gene (TCRgamma) rearrangements in patients with MF and to establish whether a clinicopathological re-evaluation of lesions previously unclassified or considered to be non-neoplastic entities but found to be monoclonal allowed the recognition of additional cases of MF. METHODS: Included in the study were 116 patients, seen at our Institute from April 2002 to September 2003 and tested for TCRgamma rearrangements. Thirty-six patients were affected by clinically and histopathologically proven MF, while the remaining 80 cases had not been classified or had been classified as non-neoplastic entities. The sensitivity of the molecular analysis was determined on the basis of the results obtained in the 36 patients with MF. The 29 cases of the second series of patients found to be monoclonal were clinically and histopathologically re-evaluated. RESULTS: Clonal rearrangements were found in 87.5% of patients with plaque stage MF and in 20% of those with patch stage MF. The clinicopathological re-evaluation allowed us to reclassify 15 of 29 monoclonal cases of the second series of patients as MF. CONCLUSIONS: The study showed that the PCR-heteroduplex technique can determine a high percentage of monoclonality only in plaque stage MF. However, in spite of the low sensitivity of the method, several cases previously unrecognized could be reclassified as MF when their clinical and histopathological features were re-evaluated taking into account the clonality of the lymphocytic infiltrate.

Rolf T. Larsen SSN: 526-78-6642 Page -4 and final-

PMID: 16086751 [PubMed - indexed for MEDLINE]

Lay Analysis:

This British Journal of Dermatology article reflects on the Stanford Hospital CL comment that no gamma chain was detected does not support the impression of MF. This is true, but since this Pt’s clinical diagnosis was that of patch stage MF and only 20% of patch stage Pts tested showed any clonal infiltrate rearrangements, there is no firm expectation that the assay would show clonality in a patch stage assay. Thus, this clonality testing neither affirmed nor refuted the existing clinical impression. It did, however, strongly indicate that if the Pt has MF, it has not yet advanced to the plaque stage.

This comment from a website (The Doctor’s Doctor) of Paul K. Shitabata, M.D., a pathologist, bears consideration in assessing the probative value of the Stanford Lab assay: “Most cases of MF are neoplastic T helper cells which are CD4 positive. These show gene rearrangements of the T cell receptors; usually of the alpha/beta receptors, but occasionally of the gamma/delta receptors.”

and

“Early MF, however, is not uncommonly PCR negative for TCRG rearrangement.”

Duvic M. - Cutaneous T-cell lymphoma. Program and abstracts of the 64th Annual American Academy of Dermatology; March 3-7, 2006; San Francisco, California. Discussion group 417.

Further from Dr. Shitabata: “The pathologist is often faced with making the diagnosis of the early patch stage. If the classic histologic features are present associated with characteristic clinical features, the diagnosis can usually be made.”

“Focal parakeratosis, sprinkling of lymphocytes in the lower layers of the epidermis, fibrosis of the papillary dermis, and scattered lymphocytes along the dermal-epidermal junction are key histopathologic features of patch stage MF.” Olsen E. - Cutaneous T-cell lymphoma. Program and abstracts of the 64th Annual American Academy of Dermatology; March 3-7, 2006; San Francisco, California. Symposium 309.

I request a C&P exam for my claim that embodies the necessary punch and slice biopsies and other assessment studies required to provide the histopathologic features needed to make a specific diagnosis.

Rolf T. XXXXXX

Claimant

================================

Comments, Please!

Ralph

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  • HadIt.com Elder

“States Medication seems to help. No side effects.”

"States “no history of flare ups.”

“His work is not affected”.

States I am “not taking any medication for the C-Spine and or right arm

These are all factual errors and your rep will probably call them that in the appeal. Since these factual errors are such core issues the exam is not worth the paper it is written on. Let the VA know they wasted their money getting this opinion. Report this doctor to his licensing agency. Sometimes in trying to write a report that they think the VA will like these guys become incompetent.

A serious issue involves the side effects of the medication. If the side effects are listed by the manufacturer and their is a legal restriction on operating heavy equipment or driving then the guy disregarded the law by in making his assessment.

His comment that your work is not affected is his medical opinion and not necessarily based on your subjective comments to him about work. He based this on his diagnosis of a mild spine condition. I see no reference to medical tests such as MRI's and EMG's. If doctors recommended fusion you must have some herniated discs. Why is there no mention of disc herniation in this report? An EMG is very important. Did you have one and why are the results of the EMG not discussed. These medical tests would force a change of diagnosis and that is what is needed to shoot this guy down.

He really covered his ass by stating that you are not taking medication for the c-spine. When your doctors prescribed the medication they usually put in the records and it might even be on the bottle what it is for. Find the treatment notes when they were originally prescribed as to why they were prescribed and submit them as evidence of the factual error.

If you can find the original prescription notes and they state for c-spine pain and there is a legal requirement that you cannot operate a vehicle then this guy is toast.

Has the SSA made any decisions about your spine condition? A trick an attorney taught me was to apply for food stamps and tell them you cannot work for medical reasons they will give you a form to take to your doctor, or in any other way possible get a copy of the medical release form that Social Services uses for determining if you are able to work. Take it to your primary doctor and tell him to fill it out. He will be required to fill out sections on your ability to work. I did this and my primary wrote up that I could not work ever again in my life. That would end any speculation as to whether or not your work is affected. The social service work release has a place for diagnosis. My primary doctor put on there "Cervical disc herniation" verified by MRI. Ridiculopothy verified by EMG. Did not respond to physical therapy, These were the minimal requirements for total disability for SSD. I got SSI for disc herniation. I wonder what the VA would do if you got awarded SSD for a service connected spine condition?

Edited by Hoppy (see edit history)
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Jim, They might give you 10 percent for the Cervical Arthtiris accordingot the measurements. If you have had Fusiuon, I think I remember you did, Then the ROM should be less than what the Doctor said.

I would consider gertting an Independant Medical Opinion to rebut this C@P.

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Jim, They might give you 10 percent for the Cervical Arthtiris accordingot the measurements. If you have had Fusiuon, I think I remember you did, Then the ROM should be less than what the Doctor said.

I would consider gertting an Independant Medical Opinion to rebut this C@P.

These are thae values I came up with

my Combined range of motion 110 = 20% the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.....

my MRI and xrays say I have reversed lordosis

my combined range of motion 150= 10% the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees;

I am not sure what to do, I faxed all this stuff and my rebuttal letter to my DAV VSO this morning, I am going to try and call him in a few minutes. I may end up faxing it all to the congressional staffer who attended my meeting at the VARO in July.

Every C&P except the one for depression has been fuked up like this, its no wonder a vet cant get a fair shake in this system................and no I didnt get the fusion, my heart disease and blood thinners are preventing this from happening

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My VSO said you get what you paid for, you paid nothng for the exam, you got nothing in return..........I told him I was going to ask for a Formal DRO Hearing, he said your not a doctor your opinion doesnt mean squat, I said my evidence disputes what the C&P Report says...............guy is a BUT WIPE :blink: Being a criminal investigator for many years taught me how to collect and present evidence. Me presenting my case is the only way I am gonna get a fair shake!

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  • HadIt.com Elder

FLHRCI,

The only way you will truely get a fair shake is if you get a IMO. I can never stress enough to any Veteran who deals with the VA that a IMO is the best thing you can do for yourself in this process.

Doing this will put you way ahead of the game, and save you loads of frustration. It will not matter how much evidence you present to the VA, the KEY is a medical opinion from a board certified doc that specializes in the condition claimed.

If any Vet thinks they will receive a fair shake at a C&P they are mistaken, C&P's are a coin flip, and you take your chances. IMO's will defeat a bad C&P before it happens or at least put you into the benefit of doubt rule.

Edited by JR Reihs (see edit history)
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FLHRCI,

The only way you will truely get a fair shake is if you get a IMO.

I cant afford a loaf of bread let alone a IMO, I have 3 letters from neurosurgeons who state whats wrong with my neck, along with the MRI's and X rays. I think me presenting these to shoot down the quaks report is adequate?

A trick an attorney taught me was to apply for food stamps and tell them you cannot work for medical reasons they will give you a form to take to your doctor, or in any other way possible get a copy of the medical release form that Social Services uses for determining if you are able to work. Take it to your primary doctor and tell him to fill it out. He will be required to fill out sections on your ability to work. I did this and my primary wrote up that I could not work ever again in my life. That would end any speculation as to whether or not your work is affected. The social service work release has a place for diagnosis. My primary doctor put on there "Cervical disc herniation" verified by MRI. Ridiculopothy verified by EMG. Did not respond to physical therapy, These were the minimal requirements for total disability for SSD. I got SSI for disc herniation. I wonder what the VA would do if you got awarded SSD for a service connected spine condition?

I think I am gonna do what hoppy suggest............

Edited by FLHRCI (see edit history)
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  • HadIt.com Elder

FLHRCI

My point was if you could get SSD for a spine condition and you have such evidence that qualified for SSD and gave it to the VA, what would the VA do? Would they give you an extra schedular rating or can you get a higher rating from the VA. I just do not know the answer to this question. There was a time when they VA would rubber stamp non-service connected claims for pension if the SSA had already granted total disability. I have gotten the impression that the VA does not take spine conditions as seriously as the Social Security system. This is something you should bring up with the congressman’s office. It is my understanding that the reason doctors put you on total disability for disc herniation is to keep the condition from degrading. I guess the VA doesn’t give a sh_t if you spend your old age in pain.

I have two herniated cervical discs. Lately they have produced minimal symptoms. I went through one “flare up” that lasted one and a half years. Not only did I not work I did not even go fishing for two and a half years. Another “flare up” lasted six months. I could not turn my head to the left. The pain by mid day was so intense I just did nothing. I begged the VA to operate on me. They told me it might go away and they were right it went away.

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