hypertension Hypertension And Heart Failure

[JessM]

I have a few question, but here is a little background first. I served in the Navy from 1993-2003. When I got out, I was awarded service connection and compensation for Asthma 30%, Acid Reflux 10%, Tinnitus 10%, and Hypertension 10%. I have a few others rated at 0% but do not remember them off the top of my head.

In January/February of this year (2015) I went to VA medical with some complaints and was subsequently diagnosed with Cardiomyopathy. To be frank, I am a bit unclear about all my diagnosis; it has been a bit of a trial for my family considering I just turned 40 I feel shellshocked. In the initial diagnosis I was told I had an enlarged heart and from there I had an ECHO and was told that I have an EF<10%. Since then I have had a catherization and 2 stents placed in 1 artery. I go back in for surgery on June 12^th to have another stenting procedure on a different artery.

So perhaps I jumped the gun but in March I applied for compensation for the heart failure. I recently received back the denial notice. It was perhaps my understanding that because I had been diagnosed with service connected hypertension and have received compensation for it since I separated in 2003 that the heart failure would be related to that hypertension, especially since I was told by a VA doctor that part of my heart failure was related to the hypertension.

I am going to file my appeal, but I wanted some advice before I do so, don't want to jump the gun again. What should I actually appeal? Their language in the denial notice speaks to not having any complaints or symptoms while active duty, do I need to spell out in my appeal that I am claiming the heart failure is a direct result of the hypertension? Any other items that I need to consider?

Any advice is greatly appreciated.

[vern2]

Sounds like hypertensive heart disease, but the HTN leads to heart disease. My cardio doc stated that my HTN had the effect of causing the heart disease. Can you get the VA doctors to connect the two conditions. separate ratings as noted by other posts. The fact you have had stents leads me to suspect you have CAD as well. Your 10% EF is a cause for alarm! Is the enlarged heart or blockage or what is the cause? Need to get this checked out ASAP! Review your SMR and see if any notice or complaints of heart issues while on AD. The usual VA tactic is to deny if not noted while on AD. How do you overcome this? Finding a nexus is the key.

Did you have any ECG, EKG while on AD? If you can get a cardio doc to connect the HTN and subsequent heart disease then makes your appeal much stronger. Is all your medical care done at VA?

[Berta]

Thanks, I missed reading the scan when I replied this AM....

Technically the VA is right in that decision. You do need an IMO/IME, that follows the IMO criteria here at hadit.

The fact the you are SC for the HBP should help but you have to claim the heart conditions (use the specific medical diagnosis)

has been caused by the HBP (thus secondary to it) and the IMO doc has to give a full medical rationale for that.

You could hope to get that type of nexus from a C & P VA doctor, but I sure would not count on that at all.I just succeed on a HBP 1151 claim.

I had the denial reversed very fast because of 4 CUEs they made in it.

I cant get info on who did the posthumous C & P report. I astill think it was the guy who fills their water cooler paper cup dispenser.

But even a PA or a nurse, if not some bogus opiner, does not have the cardio qualifications to really opine on cardiac and HBP claims.

[JessM]

First, I want to thank everyone for their advice, it has been extremely helpful in trying to get my head straight, as far as this is concerned anyway.

Today I found HealthVet web site and downloaded my medical records. I am not a doctor nor have I ever worked in the health care field so it is very slow going. I do not know most of the acronyms that are used. Google is my friend in this. J

As I am at work I am unable to donate my full attention to the record, have just scanned the almost 300 pages over the last 5-6 hours. One of the things I was really looking for but could not find was any wording as to the causation of my HF. I found plenty of test results and it was mentioned over and over that I have an EF<10%, but I couldn’t find one sentence that spoke to the ‘WHY’ of it.

During my 1^st appointment, after my ECHO, when the practitioner was discussing the ECHO results she specifically stated that part of the damage to my heart was due to long term high blood pressure. However, I have read over her notes on that appointment and I find no mention of it. I do not see her again until after my stent procedure on June 12^th, so at that appointment I will ask her about it and request that she places the note into my VA record.

[JessM]

Hello again,

I have been doing some more research and looking through my medical records. These are some pertinent facts that I have found.

· 12 Mar 2015 - Cardiac Intervention Note

o New onset HF, Ischemic CM

· 04 Mar 2015 - Left and Right heart Catherization

o Indications: Cardiomyopathy

o Left Heart Catheterization

§ Summary: 2 vessel CAD

§ Dominance: Right dominant

o Right Heart Catherization

§ ?

o Final Diagnosis for Left and Right heart Catherization on 03/04/2015

§ Subtotal (99%) occlusion in mid RCA

§ Subtotal (99%) occlusion in mid LCx

§ Elevated wedge pressure c/w left sided HF

§ Pulmonary hypertension

· 23 Feb 2015 - Cardiology Outpatient Consult

o Assessment/Plan

§ Heart Failure with diastolic and systolic dysfunction, EF of <10% NYHA Class II-III, Stage C

· 20 Feb 2015 - Echocardiogram Summary

o Referred for evaluation of dilated cadiomypathy

o Overall left ventricle systolic function is severely impaired with an EF<10%

o Restrictive LV filling pattern, consistent with elevated LA pressure

o The left ventricle is moderately dilated

o The right atrium is moderately enlarged

o Mild mitral regurgitation present

o Moderate tricuspid regurgitation present

o There is moderate pulmonary htn

Then I did some research and found this reference (M21-1, Part III, Subpart iv, Chapter 4, Section E) in the general claims process.

Under section H, Documentation required to support a diagnosis of Arteriosclerotic heart disease (also known as Ischemic heart disease (IHD) and Coronary artery disease (CAD)) there must be documentation of objective testing including ECG or EKG findings, treadmill testing, or cardiac catherization. I have the catherization done on March 4^th 2015.

Section I, requirement for documentation of Cardiac Hypertrophy, dilation, or need for continuous medication states objective evidence (hypertrophy and/or dilation must be documented by EKG, ECHO, or x-ray) must show that cardiac hypertrophy (or dilation) is present and whether continuous medication is needed. My ECHO states that my left ventricle is moderately dilated and every entry from cardiology has medications as part of my “Assessment/Plan.”

The next sections talk about METs, but according to section k I do not have to have the test as an ECHO shows my EF<10%.

Under section n, Grating service connection for arteriosclerotic manifestations due to hypertension, it states:

If additional arteriosclerotic manifestations are subsequently diagnosed in a Veteran with SC hypertension, grant service connection on a secondary basis through the relationship to hypertension for any of the following

· cerebral arteriosclerosis or thrombosis with hemiplegia

· nephrosclerosis of the kidneys with impairment of renal function, or

· myocardial damage or coronary occlusion of the heart.

My Catherization on March 4^th shows Occlusions in mid RCA and mid LCx.

So after all of this, what am I missing? Berta, you mentioned that the VA was right in their decision and that I would need an IMO/IME. It seems to me by their own rules and regulations that I should be awarded Arteriosclerotic Heart Disease. Was I denied because I wasn’t specific enough?

I know this post was really long, I appreciate everyone who worked their way through it.

Edited May 16, 2015 by JessM

[Berta]

"Was I denied because I wasn’t specific enough? "

That was my impression..unless they did have all available medical records from you.

And sometimes we have to explain things to them like they are 10 years old.

Can you scan and attach here or list what they used on the the Evidence List in the decision?

The Evidence List in a decision is as critical as their Reasons and Bases.

If you sent them critical probative evidence that is NOT in the Evidence list, they have committed a CUE...

They have done that to me many many times over the past 20 years and recently as well, and I had to write to Allison Hickey about that.

My evidence not only was verified by a Vet rep 's call from my VARO but I also listed it all on my 5103 form.

STILL they ignored it.

Either ,in your case, they ignored critical medical evidence or they did not have the evidence they needed for a proper decision.

In my past claims, as widow of a veteran, I used every diagnostic medical term that appeared in the medical records. I often had to look up acronyms and use Goggle to understand what the terms meant because I knew that the VA would not really search through a stack of medical records to find what they needed to have.

You DO have very good evidence, and maybe it can be presented along with a Reconsideration Request.

But that does not stop the NOD clock.

Reconsideration Requests are explained here under our search feature.

Edited May 16, 2015 by Berta

[JessM]

So, for full disclosure on my request for compensation:

JESS

This page is a continuation of VA form 526EZ.

**************Continued from block 9 21-526 EZ

New Claimed Disabilities:

1. heart failure

Reopened Disabilities:

1. gout

2. type 2 diabetes

**************End continued block 9 21-526 EZ

Under Item 10, "list VA Facilities" I put:

Carl T. Hayden VA Medical Center, Phoenix, AZ: 01/01/2015-Present

VA Puget Sound Health Care System, Seattle, WA: 01/01/2006-12/31/2013

I also submitted private medical records to support my gout and diabetes claims.

Here is what they listed for Evidence.

Evidence Considered

In making our decision, we considered:

· Rating Decision, and all evidence contained therein, dated September 18, 2014

· DD Form 214, Certificate of Release or Discharge from Active Duty, from July 20, 1993 through April 4, 2003

· Private Treatment Records, Shoreline Family Medicine, received March 18, 2015

· Outpatient Treatment Records, Puget Sound VA Medical Center, from July 31, 2004 through June 26, 2008

· Service Treatment Records, received April 10, 2015

· Outpatient Treatment Records, Sun City VA Medical Center, from April 17, 2015 through April 22, 2015

· Outpatient Treatment Records, Phoenix VA Medical Center, from June 10, 2014 through April 15, 2015

· VA Form 21-526 EZ: Application for Disability Compensation and Related Compensation Benefits, dated March 18, 2015

· VA Form 21-0820 Report of General Information, VAMC Puget Sound, No records beyond 6/26/2008, dated April 15, 2015

I did not submit my claim until after the ECHO and Catherization was done. In fact, I submitted the claim when I was home recovering from my 1st stent procedure.

I was also denied for Gout and Diabetes but I understand those rulings as I was not officially diagnosed with either condition until after the 1 year presumptive period (23 months after separation for diabetes and 36 months for gout). So I am gathering my evidence for those cases. One of the best things I did is when I separated (besides making the VA claim) was that I made a copy of my service medical record. So I am going through it now looking for medical reviews and lab test results to support my claims that both started in service (uphill battle, I know).