My Va Rating Decision Feb 2015

chiefhouse00 · March 10, 2015

Greetings

I've attached a copy of my recent VA Rating Decision that I received a couple weeks ago. I was very upset with the rating decision (but have calm down a little) and would like you to take a look at it and provide comments and recommendations. I was so mad about the ratings that I requested my earlier post "Stun" be removed but after realizing that all of you are there to help, ask that it be reinstated. So, thanks for listening.

Best Regards

Chiefhouse

My VA Rating Decision 2015.pdf

Edited March 10, 2015 by chiefhouse00

Berta · March 10, 2015

The denied issues, in my opinion will need an inservice service nexus ,as well as an IMO, based on what I see here.

Is the DMII from AO in Vietnam?

If so have you ever claimed PTSD?

Do you have continuous and current treatment records for all of the denied issues?

georgiapapa · March 10, 2015

chiefhouse00,

For the medical conditions where the VA continued your ratings at the same percentage levels, Google 38 CFR part 4 and find the sections covering your particular medical conditions. In the Schedule of Ratings for each of your medical conditions, you will see boxes listing symptoms and different percentage levels. Using the medical evidence you submitted, compare the symptoms listed in your evidence with the symptoms listed in the different boxes. The box containing more of your symptoms is the percentage level you should have been awarded by the VA.

In regards to the medical conditions where the VA denied your claims stating the evidence did not show the conditions were caused by or connected to your military service, you will probably need some good IMOs from doctors specializing in the diagnosis and treatment of the medical conditions denied by the VA.

Good luck to you.

GP

carlie · March 10, 2015

Greetings

I've attached a copy of my recent VA Rating Decision that I received a couple weeks ago. I was very upset with the rating decision (but have calm down a little) and would like you to take a look at it and provide comments and recommendations. I was so mad about the ratings that I requested my earlier post "Stun" be removed but after realizing that all of you are there to help, ask that it be reinstated. So, thanks for listening.

Best Regards

Chiefhouse

I am just going to focus on the issue of SC for "depression and anger associated with medical problems", being denied.

1st - I feel the claim should be for depression, secondary to SC'd disabilities and perhaps

the vba should have written / adjudicated it as such.

2nd - the reason they have denied as stated is that there is NO diagnosis of depression of record.

Without a diagnosis of depression in the records, no further development is done.

Since you feel your depression is secondary to your SC'd conditions, then of course there would be nothing to support the condition in your SMR/STR's.

3rd - their BS regarding SC for the purpose of establishing eligibility for mental health treatment

is also redundant. Your profile here shows you are SC'd at 90%.

At SC of 50% or higher the VAMC's are to provide medical care for all of your needs

whether they are SC'd or non - SC'd, this is inclusive of MH care.

4th - in relation to MH - the decision states, "The VA medical opinion found no persistent disability".

I personally would want to review where this specific opinion came from and EXACTLY what this

opinion DOES STATE.

Hope this helps a vet.

jmho

chiefhouse00 · March 10, 2015

Greetings

Here are the C&Ps for headaches and neck stiffness claims. Both of these aliments are service-connected. Please review and let me know your opinion and recommendations. Thanks

LOCAL TITLE: MEDICAL C&P REPORT

STANDARD TITLE: INTERNAL MEDICINE C & P EXAMINATION CONSULT

DATE OF NOTE: FEB 11 ENTRY DATE: FEB 11, 2015

URGENCY: STATUS: COMPLETED

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran: (Me)

Indicate method used to obtain medical information to complete this

document:

[X] 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.

Evidence review

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

Was the Veteran's VA claims file reviewed? Yes

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

Veteran's VA claims file: C-file reviewed in VBMS and virtual VA. CPRS.

MEDICAL OPINION SUMMARY

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

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Please provide the following

clarification: Veteran is claiming headaches. He complained of frontal

headaches in service. His VA treatment records note of headaches/tension

headaches. Please provide an opinion as to whether it is at least as likely

as not that the veteran's current headache diagnosis was incurred in or

caused by his complaints of frontal headaches during military service.

Please provide a rationale.

POTENTIALLY RELEVANT EVIDENCE:

STRs - frontal headaches (tabbed)

VA treatment records - headaches/tension headaches

b. Indicate type of exam for which opinion has been requested: Medical

Opinion Only

TYPE OF MEDICAL OPINION PROVIDED: [MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION]

b. The condition claimed was less likely than not (less than 50%

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

or illness.

c. Rationale: Veteran with claim of service connection for headaches.

Based on the veteran's current VHA treatment records, veteran with tension

headaches. Current diagnosis of tension headaches is consistent with

veteran's known neck pain from cervical degenerative disc disease which can

be a common trigger of tension headaches. Current diagnosis of tension

headaches is also consistent with the description of the headaches by the

veteran in CPRS VHA Primary Care Outpatient Note dated 10/30/13, described

as "... having pain to neck, with tension which climbs to the back of his

neck and onto his scalp." Although veteran with a remote history of

frontal headaches in his service medical records (STR 12/11/69 and

10/5/71), based on the description/location of these headaches in service,

these frontal headaches in service are NOT consistent with tension

headaches and therefore are unrelated to the veteran's current diagnosis of

tension headaches. In addition, there is no objective evidence of

continuity between the veteran's current tension headaches and military

service. Therefore the veteran's claimed headaches with a current

diagnosis of tension headaches is less likely than not incurred in or

caused by the claimed in-service injury, event or illness.

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

Date/Time: 03 Feb 2015

Note Title: MEDICAL C&P REPORT

Date/Time Signed: 03 Feb 2015

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

Neck (Cervical Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: (ME)

Indicate method used to obtain medical information to complete

this document:

[X] In-person examination

Evidence review

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

Was the Veteran's VA claims file (hard copy paper C-file)

reviewed? [X] Yes [ ] No

If yes, list any records that were reviewed but were not

included in the Veteran's VA claims file: VBMS/CPRS

1. Diagnosis

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

Does the Veteran now have or has he/she ever been diagnosed with

a cervical spine (neck) condition?

[X] Yes [ ] No

[X] Other Diagnosis

Diagnosis #1: CERVICAL DEGENERATIVE DISEASE

ICD code: 722.4

Date of diagnosis: 2004

2. Medical history

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

a. Describe the history (including onset and course) of the Veteran's

cervical spine (neck) condition (brief summary): VETERAN IS HERE FOR

CLAIM OF NECK STIFFNESS DUE TO SC HEPATITIS C. THIS WAS DIAGNOSED IN

RECORDS AS CERVICAL DEGENERATIVE DISEASE RIGHT HANDED

MILITARY: Air Force 8/1969-8/1999

WORK: COMPUTER LOGITICIAN

VETERAN STATE:

ONSET: 1985 PLAYING BASKETBALL AND KNOCKED DOWN AND WENT TO

ER. INITIAL C&P (2000) EXAM WAS IN DETROIT. TOLD THAT HAD

BULGING DISC IN CERVICAL REGION. WORSENED IN 2013 WHEN FELL DOWN THE

STEPS 6-8 STEPS AND HIT BACK OF HEAD AGAINST WALL HAD BEEN PLACED ON NEW

MEDICATION WHICH WAS SUPPOSED TO BE TAKEN AT NIGHT FOR PROSTATE. SEEN AT

TAMC. STILL WITH PROBLEMS WITH NECK.

GIVEN BRACE NO THERAPY.

PAIN: CONSTANT "SHARP/DULL" 6/10

FLARES: 9/10

TRIGGERS: UNKNOWN BUT THINKS MAYBE STRESS, OR POSITIONAL.

POSSIBLY SITTING TOO LONG SO GETS UP WALK AROUND EVERY 20 -30 MIN.

FREQ OF FLARES: 3 TIME/WEEKS

TREATMENT: TRIES TO RELAX. BAYER ASA WITHOUT SIDE EFFECTS

DURAION: 1 HOUR

LOCATION: RIGHT WORSE THAN LEFT

BRACE WORN

5/22/70 neck still pain check xray

5/22/70 cervical xray no sig agn

5/27/70 eval neck cspin neg, still painful

6/12/96 eval stiff neck dx cervical strain/sprain

2/1/00 rating neck stiffness denied

6/3/01 er eval neck pain dx wryneck

6/18/01 gi eval 16 week eval peg/ribavarin went to er for

neck pain june 3, dx with muscle spasm and given nsaids, felxeril dx ms

pain in neck

7/11/01 gi eval peg/ribavarin previous neckpain/muscle spasm

resolved.

7/29/04 mri cerical disc c3-4.

8/13/04 neuro eval left ulnar dist pain. mri disc c3-4. dx

ulnar compression

2/22/06 va eval notes dx djd cervical and lumbar

8/18/06 eval neck pain. l sided neck pain x 1 day. dx

cervicalgia

3/14/07 neuro eval neck and back pain f/u posterior neck

pain. no dx given

2/29/08 va initial no mention of neck pain

4/3/12 er eval syncope hurt head, neck back dx syncope

4/3/12 ct cervical degen dz.

4/4/12 neck and back pain noted

5/4/12 er eval for ha and fver. notes neck stiffness and sub

acute ha x 1 mo after fall. dx fever, ha, uri, htn

5/30/12 neuro eval note neck and back pain

1/18/13 va eval syncope. out for 2 min with neck pain. wear

neck brace

1/19/13 mri neck deeggn

9/3/13 vae neck degen spine not incurred in service.

11/4/13 neck pain and ha since accident in may 2012. taking

neurontin and fioricet. known oa of the cervical spine dx cervicalgia,

va eval neck pain/ha since 2003 injured in 1970

1/6/14 neck pain since 1970.

b. Dominant hand:

[X] Right [ ] Left [ ] Ambidextrous

c. Does the Veteran report that flare-ups impact the function of

the cervical spine (neck)?

[X] Yes [ ] No

If yes, document the Veteran's description of the impact

of flare-ups in his or her own words: SEE ABOVE

d. Does the Veteran report having any functional loss or

functional impairment of the cervical spine (neck) (regardless of

repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional

loss or functional impairment in his or her own words: SEE ABOVE

3. Range of motion (ROM) and functional limitations

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

a. Initial range of motion

[ ] All Normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0-45): 0 to 25 degrees

Extension (0-45): 0 to 10 degrees

Right Lateral Flexion (0-45): 0 to 25 degrees

Left Lateral Flexion (0-45): 0 to 25 degrees

Right Lateral Rotation (0-80): 0 to 30 degrees

Left Lateral Rotation (0-80): 0 to 25 degrees

If abnormal, does the range of motion itself contribute

to a functional loss? [ ] Yes, (please explain) [X] No

Description of pain (select best response): Pain noted on exam but does

not result in/cause functional loss

If noted on examination, which ROM exhibited pain (select

all that apply)?

Forward flexion, Extension, Right lateral flexion, Left

lateral flexion, Right lateral rotation, Left lateral rotation

Is there evidence of pain with weight bearing? [X] Yes [ ] No

Is there objective evidence of localized tenderness or pain

on palpation of the joint or associated soft tissue of the cervical

spine (neck)?

[X] Yes [ ] No

If yes, describe including location, severity and

relationship to condition(s):

TENDERNESS TO PALPATION OF MUSCLES OF NECK

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at

least three repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion

after three repetitions? [ ] Yes [X] No

c. Repeated use over time

Is the Veteran being examined immediately after repetitive

use over time?

[ ] Yes [X] No

If the examination is not being conducted immediately after repetitive

use over time:

[X] The examination supports the Veteran’s statements

describing functional loss with repetitive use over time.

Does pain, weakness, fatigability or incoordination

significantly limit functional ability with repeated use over a period

of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups

Is the examination being conducted during a flare-up? [ ] Yes

[X] No

If no, does the Veteran report flare-ups? [X] Yes [ ]

No

Frequency: SEE ABOVE

Severity: SEE ABOVE

Duration: SEE ABOVE

If the examination is not being conducted during a flare-

up: [X] The examination supports the Veteran’s statements

describing functional loss during flare-ups.

Does pain, weakness, fatigability or incoordination

significantly limit functional ability with flare-ups?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

e. Guarding and muscle spasm

Does the Veteran have localized tenderness, guarding, or

muscle spasm of the cervical spine? [X] Yes [ ] No

Muscle spasm

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below: Localized tenderness

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology:

SEE ABOVE

Guarding

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

f. Additional factors contributing to disability

In addition to those addressed above, are there additional

Contributing factors of disability? Please select all that apply and

describe: Interference with sitting

Please describe:

SEE ABOVE

4. Muscle strength testing

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

a. Rate strength according to the following scale:

0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement

2/5 Active movement with gravity eliminated

3/5 Active movement against gravity

4/5 Active movement against some resistance

5/5 Normal strength

Elbow flexion:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5

[ ] 0/5