ShuMan Posted October 20, 2015 Share Posted October 20, 2015 Team, I'm thinking this is a 0%, What do you think?-Thank You!! ---------------------------------------------Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,Disability Benefits Questionnaire========================================================Indicate method used to obtain medical information to complete thisdocument:[ ] Review of available records (without in-person or video telehealthexamination) using the Acceptable Clinical Evidence (ACE) process becausethe existing medical evidence provided sufficient information on whichtoprepare the DBQ and such an examination will likely provide noadditionalrelevant evidence.[ ] Review of available records in conjunction with a telephone interviewwith the Veteran (without in-person or telehealth examination) using theACE process because the existing medical evidence supplemented with atelephone interview provided sufficient information on which to preparethe DBQ and such an examination would likely provide no additionalrelevant evidence.[ ] Examination via approved video telehealth[X] In-person examinationEvidence review---------------Was the Veteran's VA claims file reviewed?[ ] Yes[X] NoIf no, check all records reviewed:[X] Military service treatment records[X] Veterans Health Administration medical records (VA treatmentrecords)======================================================== SECTION I: Diagnosis:---------------------Does the Veteran now have or has he/she ever been diagnosed with a sinus,nose, throat, larynx, or pharynx condition? (This is the condition theVeteran is claiming or for which an exam has been requested)[X] Yes [ ] No[X] Chronic sinusitis ICD code: J32.2 Date of diagnosis: 2015SECTION II: Medical history---------------------------The Veteran reports intermittent symptoms of URI and sinusitis while inservice (so noted in STR's). He denies pre-service episodes. He hasbeenevaluated at the VA and treated. He reports several episodes per year thatrequire antibiotic treatment.SECTION III: Nose, throat, larynx or pharynx conditions-------------------------------------------------------Does the Veteran have any of the following nose, throat, larynx or pharynxconditions?[X] Yes [ ] No[X] Sinusitis1. Sinusitis------------a. Indicate the sinuses/type of sinusitis currently affected by theVeteran'schronic sinusitis (check all that apply):[ ] None [ ] Maxillary [ ] Frontal[X] Ethmoid [ ] Sphenoid [ ] Pansinusitisb. Does the Veteran currently have any findings, signs or symptomsattributable to chronic sinusitis?[ ] Yes [X] NoIf yes, check all that apply:[ ] Chronic sinusitis detected only by imaging studies (see Diagnostictesting section)[ ] Episodes of sinusitis[ ] Near constant sinusitisIf checked, describe frequency:[ ] Headaches[ ] Pain of affected sinus[ ] Tenderness of affected sinus[ ] Purulent discharge[ ] Crusting======================================================== [ ] OtherFor all checked conditions, describe:c. Has the Veteran had NON-INCAPACITATING episodes of sinusitischaracterizedby headaches, pain and purulent discharge or crusting in the past 12months?[X] Yes [ ] NoIf yes, provide the total number of non-incapacitating episodes over thepast 12 months:[ ] 1 [X] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or mored. Has the Veteran had INCAPACITATING episodes of sinusitis requiringprolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?[ ] Yes [ ] NoNOTE: For VA purposes, an incapacitating episode of sinusitis means onethat requires bed rest and treatment prescribed by a physician.If yes, provide the total number of incapacitating episodes of sinusitisrequiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12months:[ ] 1 [ ] 2 [ ] 3 or moree. Has the Veteran had sinus surgery?[ ] Yes [ ] NoIf yes, specify type of surgery:[ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other:Type of procedure, sinuses operated on and side(s):Date(s) of surgery (if repeated sinus surgery, provide all dates ofsurgery):If Veteran has had radical sinus surgery, did chronic osteomyelitisfollowthe surgery?[ ] Yes [ ] Nof. Has the Veteran had repeated sinus-related surgical procedures performed?[ ] Yes[ ] No6. Other pertinent physical findings, scars, complications, conditions,signsand/or symptoms-----------------------------------------------------------------------------a. Does the Veteran have any scars (surgical or otherwise) related to anyconditions or to the treatment of any conditions listed in the Diagnosis========================================================section above? : No answer providedb. Does the Veteran have any other pertinent physical findings,complications, conditions, signs and/or symptoms related to anyconditionslisted in the Diagnosis section above?: No answer providedc. Does the Veteran have loss of part of the nose or other scars of the noseexposing both nasal passages?: No answer providedd. Does the Veteran have loss of part of the nose or other scars causinglossof part of one ala?: No answer providede. Does the Veteran have loss of part of the nose or other scars causingother obvious disfigurement?: No answer providedSECTION IV: Diagnostic testing------------------------------a. Have imaging studies of the sinuses or other areas been performed?No answer providedb. Has endoscopy been performed?No answer providedc. Has the Veteran had a biopsy of the larynx or pharynx?No answer providedd. Has the Veteran had pulmonary function testing to assess for upper airwayobstruction due to laryngeal stenosis?No answer providede. Are there any other significant diagnostic test findings and/or results?No answer providedSECTION V: Functional impact and remarks----------------------------------------1. Functional impact--------------------Does the Veteran's sinus, nose, throat, larynx or pharynx conditionimpacthis or her ability to work?No answer provided2. Remarks, if any:-------------------========================================================VBMS P. 1 dated 07/02/2015 STR's P. 4-5 Sinusitis.STR's P. 4/7 pseudoephedrine RX for ALLERGY symptoms.STR's dated 05/26/2005 P. 4-5/93 noted 6 simultaneous diagnosis: URI,allergic rhinitis, viral syndrome, sinusitis, bronchitis and acutebronchitis.Rhinitis noted on STR's P 58/93. Being treated with medications forallergiesand nasal congestion, however in the past medical history of 04/07/2009 NOallergy or hayfever was entered in the note Link to comment Share on other sites More sharing options...
0 Reddit Posted October 21, 2015 Share Posted October 21, 2015 No, you have an honest chance with this. Just remember to answer the questions right, and described everything that happens when your sinus flairs up. Va examiner should have request an x-rays. Andyman73 1 Link to comment Share on other sites More sharing options...
0 Andyman73 Posted October 21, 2015 Share Posted October 21, 2015 Reddit,Thanks for your input, again, Shuman, I appreciate you posting this thread about sinusitis. I do suffer, and have while on AD. If not for you I probably would still be in the dark about filing a claim for that. I wish you complete success with your sinus claim.Semper Fi.Andyman Link to comment Share on other sites More sharing options...
0 ShuMan Posted October 21, 2015 Author Share Posted October 21, 2015 Reddit,Good thinking on the DBQ, I did that for my back and migraines. I have some extra evidence and will fight this one. What should be the next step when they come back with a SC 0%?Andyman73,Good luck Brother! Andyman73 1 Link to comment Share on other sites More sharing options...
0 Content Curator/HadIt.com Elder Vync Posted October 21, 2015 Content Curator/HadIt.com Elder Share Posted October 21, 2015 Shuman and Vync,Forgive me, I know it's not my thread, but this is same topic, and I don't want to forget that I saw this topic...cuz I will.I noticed that the chart says 6 or more non-incapacitating episodes per year. I have 9-12 episodes per year, and mostly treat with otc meds. I do have a few strs where antibiotics were prescribed. Do I have an honest chance with this? Or is this something that needs to be tied in with my sleep issues, and such?Andyman,The 30% rating for "more than six non-incapacitating episodes per year of sinusitis" needs to be "characterized by headaches, pain, and purulent discharge or crusting." If you see a doc for them, you might consider not taking the OTC meds before you go to the doc. It would be better to have the actual symptoms on record, not the reduced symptoms after you take OTC meds. Also, keep a "sinusitis diary" which describes when it started, symptoms, what you took, saw doc, duration, etc... I did this for migraines and it was helpful. Michael Lissak and Andyman73 2 Link to comment Share on other sites More sharing options...
0 Content Curator/HadIt.com Elder Vync Posted October 21, 2015 Content Curator/HadIt.com Elder Share Posted October 21, 2015 Reddit,Good thinking on the DBQ, I did that for my back and migraines. I have some extra evidence and will fight this one. What should be the next step when they come back with a SC 0%?Andyman73,Good luck Brother!Reddit will probably answer separately, but if they come back with 0%, collect your evidence and (preferable) a strong IMO in your favor, and file a reconsideration. The raters are supposed to take another look. It is not an appeal, but I believe you have a year to file a formal appeal. If they don't approve you, then make sure you file an appeal/NOD before your time runs out. This will preserve your original effective date and any retro you might receive for initial or an increased combined rating. Read the documentation they send you if you are not satisfied with their decision. Andyman73 and ShuMan 2 Link to comment Share on other sites More sharing options...
0 ShuMan Posted October 22, 2015 Author Share Posted October 22, 2015 Thanks Vync,I just started the process of gathering my military health records. Once I have those, I'll combine those with my VA records and go search for an IMO. Link to comment Share on other sites More sharing options...
Question
ShuMan
Team,
I'm thinking this is a 0%, What do you think?
-Thank You!!
---------------------------------------------
Sinusitis, Rhinitis and Other Conditions of the Nose, Throat,
Disability Benefits Questionnaire
========================================================
Indicate method used to obtain medical information to complete this
document:
[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) p
rocess 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.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file reviewed?
[ ] Yes[X] No
If no, check all records reviewed:
[X] Military service treatment records
[X] Veterans Health Administration medical records (VA treatment
records)
========================================================
SECTION I: Diagnosis:
---------------------
Does the Veteran now have or has he/she ever been diagnosed with a sinus,
nose, throat, larynx, or pharynx condition? (This is the condition the
Veteran is claiming or for which an exam has been requested)
[X] Yes [ ] No
[X] Chronic sinusitis ICD code: J32.2 Date of diagnosis: 2015
SECTION II: Medical history
---------------------------
The Veteran reports intermittent symptoms of URI and sinusitis while in
service (so noted in STR's). He denies pre-service episodes. He has
been
evaluated at the VA and treated. He reports several episodes per year that
require antibiotic treatment.
SECTION III: Nose, throat, larynx or pharynx conditions
-------------------------------------------------------
Does the Veteran have any of the following nose, throat, larynx or pharynx
conditions?
[X] Yes [ ] No
[X] Sinusitis
1. Sinusitis
------------
a. Indicate the sinuses/type of sinusitis currently affected by the
Veteran's
chronic sinusitis (check all that apply):
[ ] None [ ] Maxillary [ ] Frontal
[X] Ethmoid [ ] Sphenoid [ ] Pansinusitis
b. Does the Veteran currently have any findings, signs or symptoms
attributable to chronic sinusitis?
[ ] Yes [X] No
If yes, check all that apply:
[ ] Chronic sinusitis detected only by imaging studies (see Diagnostic
testing section)
[ ] Episodes of sinusitis
[ ] Near constant sinusitis
If checked, describe frequency:
[ ] Headaches
[ ] Pain of affected sinus
[ ] Tenderness of affected sinus
[ ] Purulent discharge
[ ] Crusting
========================================================
[ ] Other
For all checked conditions, describe:
c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis
characterized
by headaches, pain and purulent discharge or crusting in the past 12
months?
[X] Yes [ ] No
If yes, provide the total number of non-incapacitating episodes over the
past 12 months:
[ ] 1 [X] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more
d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring
prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months?
[ ] Yes [ ] No
NOTE: For VA purposes, an incapacitating episode of sinusitis means one
that requires bed rest and treatment prescribed by a physician.
If yes, provide the total number of incapacitating episodes of sinusitis
requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12
months:
[ ] 1 [ ] 2 [ ] 3 or more
e. Has the Veteran had sinus surgery?
[ ] Yes [ ] No
If yes, specify type of surgery:
[ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other:
Type of procedure, sinuses operated on and side(s):
Date(s) of surgery (if repeated sinus surgery, provide all dates of
surgery):
If Veteran has had radical sinus surgery, did chronic osteomyelitis
follow
the surgery?
[ ] Yes [ ] No
f. Has the Veteran had repeated sinus-related surgical procedures performed?
[ ] Yes[ ] No
6. Other pertinent physical findings, scars, complications, conditions,
signs
and/or symptoms
-----------------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
========================================================
section above? : No answer provided
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs and/or symptoms related to any
conditions
listed in the Diagnosis section above?: No answer provided
c. Does the Veteran have loss of part of the nose or other scars of the nose
exposing both nasal passages?: No answer provided
d. Does the Veteran have loss of part of the nose or other scars causing
loss
of part of one ala?: No answer provided
e. Does the Veteran have loss of part of the nose or other scars causing
other obvious disfigurement?: No answer provided
SECTION IV: Diagnostic testing
------------------------------
a. Have imaging studies of the sinuses or other areas been performed?
No answer provided
b. Has endoscopy been performed?
No answer provided
c. Has the Veteran had a biopsy of the larynx or pharynx?
No answer provided
d. Has the Veteran had pulmonary function testing to assess for upper airway
obstruction due to laryngeal stenosis?
No answer provided
e. Are there any other significant diagnostic test findings and/or results?
No answer provided
SECTION V: Functional impact and remarks
----------------------------------------
1. Functional impact
--------------------
Does the Veteran's sinus, nose, throat, larynx or pharynx condition
impact
his or her ability to work?
No answer provided
2. Remarks, if any:
-------------------
========================================================
VBMS P. 1 dated 07/02/2015 STR's P. 4-5 Sinusitis.
STR's P. 4/7 pseudoephedrine RX for ALLERGY symptoms.
STR's dated 05/26/2005 P. 4-5/93 noted 6 simultaneous diagnosis: URI,
allergic rhinitis, viral syndrome, sinusitis, bronchitis and acute
bronchitis.
Rhinitis noted on STR's P 58/93. Being treated with medications for
allergies
and nasal congestion, however in the past medical history of 04/07/2009 NO
allergy or hayfever was entered in the note
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Reddit
In the future if you can, every time you think that you are coming down with a sinus infection get to a doctor, whether it is VA or private, and get it on records, then when you have your prescription
Vync
It's not uncommon for you to verbally indicate having 5-6 non-incapacitating episodes, but not all docs write everything down. If you have medical visits showing this, it can help to counter it. Even
Vync
Andyman, The 30% rating for "more than six non-incapacitating episodes per year of sinusitis" needs to be "characterized by headaches, pain, and purulent discharge or crusting." If you see a doc for t
18 answers to this question
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