New claim & Appeals questions

[invisible]

I was med boarded through a WTU in 2011, recieved my determination in 2014. After the ourcome of the determination, I hired a Attourney. What hurt me in the determination is that the whole time since seperation, I was pregnant or breastfeeding and therefore that affected MD documentation following my seperation. Every time I went to the VA about things, they said that due to pregnancy etc OBGYN was my primary. I currently recieve 60%, but many of the things they sc with 0% or denied-which I am going to fight. So once I hired a lawyer, and I started to dilegently go to a civilian doctor, to recieve my treatment for all my issues. Fast forward, I have some areas that have empirical tests (sleep apnea, plms/rls from my awesome double board certified MD in sleep and ENT specialty)... but many of the things I recieved 0% on were due to ROM measurements not being limiting enough.

I did not discuss this with my primary care (my intent to claim/appeal bc I didn't want that to make him biased or stereorype me...many people do not understand the difference in MIL/VA disability and SSI/SSDI. They trasnfer their stereotypes of civilian disability over to MIL-related disability...), but all these issues have honestly been getting worse, and I want to get to the root issues. Anyways, my PC MD begun prescribing me gabapetin for nerve pain, cymbalta for fibromyalga, fiercet for headaches and baclopen for muscle spasms. The funny thing is that if you look at the things in my claim (whether denied, SC with any %, I meet all the related symptomology of fibromyalga). Plus there is plently of the same complaints while I was active, brought up to my medical team while in the warrior transition unit, and during my MEB. Just this last month I brought the associated questionaire for FM (It was the most important and I didn't want to overload him) for my MD to fill out. He kept delaying filling it out, and when I finally went to talk to him- he claimed at he didn't remeber diagnosing me with FM. I had even asked him like 6 months ago if other diagnostics or othger specialties needed to be considered- to confirm or rule out his diagnosis, to which he said there was no tests. He told me he didn't feel comfortable filling it out bc it was confusing and that he didn't want to fill out it wrong, and is referring me to a rhumetologist.  

Granted...I should have asked for a referral a while back. But he even seemed iffy filling out the easy ones like headaches, etc. I requested a copy of all my treatment notes from him and his MD notes are sub par and do not mention much, and in some ways contradict. They are good enough to show the rheumatologist, and a perfect segway to let him know up front I want to figure out what is actually going on. My issue is that my attourney had already filed a appeal for some of the things in my original claim, and had filed a new condition for FM. I have gone through my C&P appt, but due to my wishy-washy PC MD, I will not have much other evidence from any forms I needed the PC MD to fill out. The sleep/ENT related ones are filling out and ready, and I might want to add TMJ which I have documented in MIL, flares when the FM stuff flares, and the DDS/MD is one of the ones that mentioned I should go see a rheumatologist beacuse it seems like I have systemic musculoskeletal issues that need to be looked at- FM, tmj, arthritis DDD/DA, msucle spasms, TMJ, etc etc. 

I am dissapointed that certain primary MD's have no problem stating you have certain issues, treating and medicating, and getting paid for F/U's, but without offically diagnosising, or being willing to stand by their treatment, and diagnosis and "too confused" to fill out simple VA packets. If someone graduated medical school and residency, a VA packet is easy. One of my sisters is a MD and I talked to her at length after this happened, and she explained some of the possible reasons why, and that overall, a Rheumy and other specialty MD will be better at taking detailed notes, confidence in diagnosis, etc. 

 

Has anyone else had issues like this with a MD not cooperating?

For DDD/DA, ROM is key, is there anyt exception to that? I have been reading through stuff and the painful motion(4.59) rule would work, or under MS system, Joints (4.45) d, e and f would apply to me, plus I have bad crepedation but my ROM isn't bad enough. Is there another way or terminology? I assume the VA is going to categorize it in the way that best suits them. I do have ddd of the cervical and lumbarsacral- the SI- L5-S1 with osteophyte and boney islands. In my C5/C6 I have a buldging disc, which hasnt had a mri or CT since 2010 during my MEB. The rules they did consider were not the ones I listed above, and unless there is another reason, I guess they considered those to benefit them...

I can include my original claim, and determination details below in a bit if its is helps, just let me know. I apologize if my post is scattered. I have been reading, researching, plus I have taken some classes in A&P, and have a civilian sister who is a MD who can better explain medical things if I need clarification. My issue is that there are so many working parts and variables, not to mention the variables of the VA system. At this point, I am not letting the set back from my PC MD bring me down, I just need to refocus and learn from my oversights... I plan on expalining more, but I tend to be very thorough in figuring out and researching things and don't want to overload anyone willing to read my post. I tend to be long winded and for that, I apologize.

Thanks in advance!

Edited October 25, 2015 by invisible

[invisible]

invisible,

I see you!  Not invisible anymore, but I do know what you mean, kinda like that Clay Aiken song about being invisible, and the one line says something about being invisible, oh wait, he already is.

My wife's cousin's husband is an ER Trauma doc(she's a lawyer) and we don't ask too much of him, either.

Gotta tell you this, I didn't notice if you said, but if not, request a complete copy of your C-file and service treatment records, too.  I got my c-file this past summer, and found an old C&P exam from '06, that was never decided, but was SC this summer, from a new claim on same contention, for 30%.  So I'm filing a NOD for EED, earlier effective date.  I'm looking at $50Gs or more possibly...

So, just remember one thing, we here, are all visible, if not to our own selves, to each other.

 

Semper Fi.

Andyman

I choose the name "invisible" not because I feel invisible, but rather because I thought it might be ill-advised to use my real name, and was not in a particularly creative mood to make up a more clever username. Plus I am in the middle of starting up my own forum for something unrelated to VA type stuff, and my administrator account username is "invisible" (to be gender nuetral, males sometimes react differently to a female and if I need to moderate a thread, me being a female will in that case be a non-issue). I know the back story to my username is off-topic, but thought I would explain it anyways.

I just recently requested my personel and service medical records (I had but were lost in a move). I will have to ask my lawyer about the C-file.

[Andyman73]

Invisible,

I see(or don't?)  makes perfect sense, I think most of us use nicknames we already have, or some mix of our MOS and name.  Mine is one an older Vet where I had worked, called me..it was Andy...man, like hey man, so I adapted it to what it is here.  Back story is perfectly fine.  As for me being invisible....well...I'll leave that one for some rainy day...

You can request your C-file several different ways, through the Freedom of Info Act(FOIA), or IRIS on VA.gov, the contact us link.  Also VA form for statement in support of claim, I think the benefits counselor use that for me, he requested my complete service, service medical, and C-file.  Your C-file is based on your VA claims, and contains exam notes and such that aren't available via Blue Button on Myhealthevet. 

I found a C&P exam from 2006 for my feet that went decided and was left off the decision letter.  I have no memory of that, however I had new foot claim this past summer that netted me 30% for foot condition.  I received my C-file afterwards, and only just this past week or two discovered that old foot exam.  Which now gives me cause for NOD for EED, earlier effective date of my foot rating award.

Semper Fi.

Andyman

[USMC_VET]

VA Form 3288 is the official form for C-File requests. 
The VA now considers C-File requests as a seperate "claim" so know that if you file for your c file request and have a claim pending that they will be "combined" and one will hold up the other until both are done.

Send the http://www.va.gov/vaforms/va/pdf/VA3288.pdfForm 3288 to YOUR claims intake Center.

See below for where you send yours.

DEPARTMENT OF VETERANS AFFAIRS CLAIMS INTAKE CENTER
PO BOX 5235
NEWNAN, GA 30271-0020

FAX: TOLL FREE: 844-531-7818
DID: 248-524-4260

SERVING THESE AREAS:

ALABAMA, CONNECTICUT, DELAWARE, FLORIDA, GEORGIA, INDIANA, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, MICHIGAN, MISSISSIPPI, NEW HAMPSHIRE, NEW JERSEY, NEW YORK, NORTH CAROLINA, OHIO, PENNSYLVANIA, RHODE ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, WEST VIRGINIA, AND PUERTO RICO

DEPARTMENT OF VETERANS AFFAIRS
CLAIMS INTAKE CENTER
PO BOX 5235
JANESVILLE, WI 53547-5235

FAX: TOLL FREE: 844-822-5246 (844VACLAIM)
DID: 608-373-6690

SERVING THESE AREAS:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, ILLINOIS, IOWA, KANSAS, LOUISIANA, MINNESOTA, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, SOUTH DAKOTA, TEXAS, UTAH, WASHINGTON, WISCONSIN, WYOMING, AND THE PHILIPPINES

This is the wording i put in the Form 3288 (bolded sections are important)

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

I hereby request a copy of all documents contained in JOHN DOE’S claims folder, including, but not limited to, all documents in the right flap, left flap, and center flap, and the reverse side of any documents with writing on both sides, including all handwritten notes, post-its and all decision forms or blue sheets as they are sometimes known

Please note that this request for documents is being made pursuant to the Privacy Act, 5 U.S.C. § 552, and the Freedom of Information Act (FOIA), 5 U.S.C. § 552a, as well as 38 C.F.R.§1.550 and 38 C.F.R.  § 1.577.  Your agency has a duty to respond to this request within TWENTY (20) DAYS of the date of this request pursuant to 5 U.S.C. § 552 (a)(6)(A)(2)(i).

Additionally, although an extension of time to respond may be requested, it may only be granted for “unusual circumstances.” “Predictable agency workload” is not typically considered an unusual circumstance as stated in 5 U.S.C. § 552(a)(6)(C)(ii).   Moreover, even to the extent that unusual circumstances could be demonstrated in this instance, the time limit for the extension is limited to “10 working days” pursuant to 38 C.F.R.§ 1.553(d).

Please also be aware that your agency’s failure to respond to this request within twenty (20) days may result in the filing of an administrative appeal with the office of the Secretary of the Department of Veterans Affairs pursuant to 38 C.F.R.§ 1.557 and 5 U.S.C. §552(a)(6)(A)(2)(ii), and potentially, the filing of a federal lawsuit to compel the production of the information.

This may subject your agency to contempt of court and a fine, including attorney fees and litigation expenses in compelling the production of this information pursuant to 38 U.S.C. § 552a(g)(l) of the Privacy Act, and 38 U.S.C. § 552(a)(4)(B) of FOIA.

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

 

In my signature line is my site that has ebooks, all are free, one being on c file requests.

[USMC_VET]

Also remember that once you get your C-File you will want to keep it updated.

Example:

You got out in 2005 and filed your first claim and you request your C-file and got it today.

You notice in your file the latest record is from June 1, 2015 the last entry related to a recently closed claim.

Once a year or after every claim is finished, appeal finalized, etc. request a copy of your c file since then.

The C-File you would have gotten SHOULD cover you from your first claim to last.  2005 - June 1, 2015.

So if you request your whole c-file again they CAn and probably will charge you for copies of all the docs they already sent you.  Instead in that new request state....

"I hereby request a copy of all documents contained in JOHN DOE’S claims folder from 6/2/2015 to present and anything that may have not been included for any reason in my (1)st request for my Claims file dated (insert date for initial c-file request), including, but not limited to, all documents in the right flap, left flap, and center flap, and the reverse side of any documents with writing on both sides, including all handwritten notes, post-its and all decision forms or blue sheets as they are sometimes known"

This will ensure that you get all the updates but wont be charged for recopying.  The Government is required to provide you this information free of charge...but only once.

[Buck52]

Some Dr's will help out a veteran (veteran friendly) & Unfortunately some won't... I had the same thing happen so I got a private Doc specialist  and ask him if he would go by the VA standards (guidlines) (printed them off here on hadit) and the language they prefer  I assured the Dr The VA would not question his expertise, because its his own professional opinion.   he deserves that right by going to medical school.

 

I had ask the Dr's Secretary about what all I needed on the phone and she said yes she thinks he will help  for me to come in and explain to him what I need.

It worked 100% in my favor.

 

................Buck

[USMC_VET]

Some Dr's will help out a veteran (veteran friendly) & Unfortunately some won't... I had the same thing happen so I got a private Doc specialist  and ask him if he would go by the VA standards (guidlines) (printed them off here on hadit) and the language they prefer  I assured the Dr The VA would not question his expertise, because its his own professional opinion.   he deserves that right by going to medical school.

 

I had ask the Dr's Secretary about what all I needed on the phone and she said yes she thinks he will help  for me to come in and explain to him what I need.

It worked 100% in my favor.

 

................Buck

Just make sure they know that they need THESE words and what THESE words mean to the VA...

 

 

“is due to/caused by” = 100%

“very likely” = >90%

“much more likely than not” = >75%

“more likely than not” = >50%

 “at least as likely as not” = ≥50% (reasonable doubt)

“not at least as likely as not” <50%

“is not due to” = 0%

 

Attached is the ROUGH copy of my IMO/IME book, it has way more information than you probably need to know, but it has the references in the 38CFR and M21 for the docs reference on things like P&T, TDIU, SMC, Staged/aggravated/analagous ratings, etc.

 

 

 

HOW TO GET IMO DRAFT.pdf

Edited October 28, 2015 by USMC_VET