Jump to content
VA Disability Claims Community Forums - HadIt.com Veterans
  • veterans-crisis-line.jpg
    The Veterans Crisis Line can help even if you’re not enrolled in VA benefits or health care.

    CHAT NOW

  • question-001.jpeg

    Have Questions? Get Answers.

    Tips on posting on the forums.

    1. Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery instead of ‘I have a question.
       
    2. Knowledgeable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title.
      I don’t read all posts every login and will gravitate towards those I have more info on.
       
    3. Use paragraphs instead of one massive, rambling introduction or story.
       
      Again – You want to make it easy for others to help. If your question is buried in a monster paragraph, there are fewer who will investigate to dig it out.
     
    Leading too:

    exclamation-point.pngPost straightforward questions and then post background information.
     
     
    Examples:
     
    • Question A. I was previously denied for apnea – Should I refile a claim?
      • Adding Background information in your post will help members understand what information you are looking for so they can assist you in finding it.
    Rephrase the question: I was diagnosed with apnea in service and received a CPAP machine, but the claim was denied in 2008. Should I refile?
     
    • Question B. I may have PTSD- how can I be sure?
      • See how the details below give us a better understanding of what you’re claiming.
    Rephrase the question: I was involved in a traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?
     
    This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial of your claim?”
     
    Note:
     
    • Your first posts on the board may be delayed before they appear as they are reviewed. This process does not take long.
    • Your first posts on the board may be delayed before they appear as they are reviewed. The review requirement will usually be removed by the 6th post. However, we reserve the right to keep anyone on moderator preview.
    • This process allows us to remove spam and other junk posts before hitting the board. We want to keep the focus on VA Claims, and this helps us do that.
  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • VA Watchdog

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

  • 0

My Va Rating Decision Feb 2015


chiefhouse00

Question

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 by chiefhouse00 (see edit history)
Link to comment
Share on other sites

  • Answers 4
  • Created
  • Last Reply

Top Posters For This Question

Popular Days

Top Posters For This Question

4 answers to this question

Recommended Posts

  • 0

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?

Link to comment
Share on other sites

  • 0

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

Link to comment
Share on other sites

  • 0

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

Link to comment
Share on other sites

  • 0

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

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

[ ] 0/5

Elbow extension

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

[ ] 0/5

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

[ ] 0/5

Wrist flexion:

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

[ ] 0/5

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

[ ] 0/5

Wrist extension:

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

[ ] 0/5

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

[ ] 0/5

Finger Flexion:

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

[ ] 0/5

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

[ ] 0/5

Finger Abduction

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

[ ] 0/5

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

[ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

5. Reflex exam

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

Rate deep tendon reflexes (DTRs) according to the following

scale:

0 Absent

1+ Hypoactive

2+ Normal

3+ Hyperactive without clonus

4+ Hyperactive with clonus

Biceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Triceps:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Brachioradialis:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

6. Sensory exam

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

Provide results for sensation to light touch (dermatomes)

testing:

Shoulder area (C5):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Inner/outer forearm (C6/T1):

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Hand/fingers (C6-

Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

7. Radiculopathy

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

Does the Veteran have radicular pain or any other signs or

symptoms due to radiculopathy?

[ ] Yes [X] No

8. Ankylosis

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

Is there ankylosis of the spine? [ ] Yes [X] No

9. Other neurologic abnormalities

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

Does the Veteran have any other neurologic abnormalities related

to a cervical spine (neck) condition (such as bowel or bladder

problems due to cervical myelopathy)?

[ ] Yes [X] No

10. Intervertebral disc syndrome (IVDS) and episodes requiring

bed rest

a. Does the Veteran have IVDS of the cervical spine?

[ ] Yes [X] No

11. Assistive devices

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

a. Does the Veteran use any assistive device(s) as a normal mode

of locomotion, although occasional locomotion by other methods

may be possible?

[X] Yes [ ] No

Assistive Device: Frequency of use:

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

[X] Brace(s) [ ] Occasional [ ] Regular [X]

Constant

b. If the Veteran uses any assistive devices, specify the

condition and identify the assistive device used for each condition:

BRACE WORN FOR NECK

12. Remaining effective function of the extremities

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

Due to a cervical spine (neck) condition, is there functional

impairment of an extremity such that no effective function remains other

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Answer this question...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

×
×
  • Create New...

Important Information

{terms] and Guidelines