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ESV12B

TBI screen positive but no follow up

Question

I've read some other thread with kind of the same situation going on. Keep a long story short here. While on active duty I started seeing a doctor after a deployment and he was treating me for list of things. Post concussion syndrome was one of these things. This was 2009 and TBI was sort of being talked about but I didn't ever put to much thought into it. I was more worried about being able to sleep and wake up with the prescriptions I was taking. I believed that my only problem at the time was nightmares and sleeping.

I enrolled in the VA in 2010 and had a TBI screening in 2013 that was positive. I vaguely remember a few questions about what sort of blasts I was exposed to and if I ever was unconscious. The usual questions when discussing TBI. And that was it. They told me I was fine. My TBI screen was negative they said. In 2014 I pulled all my doctor notes from the VA via the Blue Button feature from myhealthyvet. After reading years of notes I read about the TBI screen. There were notes that the TBI screen done in 2013 was positive and that I was asked if I would like to have follow up care and further examinations to determine the severity of TBI if any. The notes specifically said that service member agrees to follow up for positive TBI screen.

I filed a claim at the end of 2014 for TBI. I was denied and I filed a NOD. I stated some brief but valid reasons why I disagree (the big one being that I was diagnosed and treated for post concussion syndrome while on active duty) with the VA's decision.

I have about 40 days left of my 60 days to tell them I would like to have everything reviewed by the DRO or go the route of a traditional appeal. I'm leaning towards the DRO but would like some insight if that is the best way to go.

And also if anyone has a answer, why the VA likes to bust balls when it comes to a post concussion syndrome diagnosis when making a TBI claim. And even when TBI is diagnosed I've read stories of guys not getting the proper attention.

For years my I tell my PCP my problems and she refers me to mental health. I'm this depressed sack of shit who thinks my PTSD and depression are my problems and have been taking all sorts of meds over the past 6 years form the VA for this. But not once have they tried to possibly treat TBI or even take a peak and see if maybe that's the reason behind some of the issues I have.

I've read about the poly trauma units and that it could be a good place to start. My closets VA that would have something like that is 50+ miles from me. I go to a small clinic that's closer and they have just about everything to accommodate me minus the big things like ED, MRI, pharmacy and poly trauma.

Anyone ever dealt with the poly trauma units before? if so, how did everything go. I'd really like to explain some of the issues I am having to someone other than my PCP and not just be given more meds.

At the very least, thanks for listening to my concern(s). Have a good night and thanks for allowing me to be part of this community.

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You not only seem to have solid proof of TBI due to your service but you might have PTSD as a result of the TBI incident as most TBIs are, in fact, stressors. VA must rate both of these as separate conditions if they are claimed and proven.

Can you scan and attach here the VA's Reasons and Bases for denial and also we need to see the evidence list. (cover the C file number and your name prior to scanning it)

Others here will chime in as to the poly trauma stuff...I am very concerned that VA said at first the TBI screen was negative, but then you found it had been in fact positive for TBI.

This is why every vet needs to have copies of their VA med recs as well as copies of their C & P exams....will VA try to cover up medical findings?

You bet they will if they can get away with it.

They might not even have attempted to get your SMRs or, even if they did, the VA does not always employ people who can actually

read.

Welcome to hadit!

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I'm working on getting everything scanned and into folders. Here is what I have so far. These were the notes from 2013 for the positive TBI screen that was positive but I was told was negative and nothing ever happened after this regarding the TBI concerns.

Date/Time: 27 Sep 2013 @ 1224
Note Title: H&P PRIMARY-CARE PROVIDER NEW-PATIENT
Location: VA Salt Lake City Hlthcare Sys

************MEDICAL DECISION-MAKING and FOLLOW-UP************* ASSESSMENT/DIAGNOSIS & PLAN:
6.pos TBI screen: consult for further eval.

CLINICAL REMINDER ACTIVITY  TBI Screening:
                      TRAUMATIC BRAIN INJURY SCREENING    Has the Veteran already been diagnosed as having TBI during OIF/OEF    deployment?

    No


    Section 1: The Veteran experienced the following events during OIF/OEF    deployment:   

Blast or Explosion IED (improvised explosive device), RPG (rocket    propelled grenade), Land Mine, Grenade, etc.    Blow to head (head hit by falling/flying object, head hit by another    p erson, head hit against something, etc.)


    Section 2: The Veteran had the following symptoms immediately    afterwards:   

Being dazed, confused or "seeing stars"    Not remembering the event


    Section 3: The Veteran had the following problems which began or got    worse afterwards: 

   Memory problems or lapses    Balance problems or Dizziness    Sensitivity to bright light    Irritability    Headaches    Sleep problems


    Section 4: The Veteran relates he/she is currently having or has had    the following symptoms within the past week:   

Memory problems or lapses    Sensitivity to bright light    Irritability    Headaches    Sleep problems    Positive screen.    Positive screen.  Results of TBI Screen discussed with patient.    Consult for further evaluation discussed with patient and the patient    agrees.  Consult order entered.    TBI Comprehensive Screening Consult.

 

I never had any follow up to the from the TBI screening from these notes. I was treated for PTSD and have been since 2008 while on active duty but never had a diagnosis until 2010.

The original denial letter is not saved to my computer yet but here is what was mentioned in that notice:

Claimed received on July 7, 2014.

REASONS FOR DECISION

Service connection for traumatic brain injury,

Service connection for traumatic brain injury is denied since this condition neither occurred in nor was caused by service.

Your military occupational specialty during active duty was Combat Engineer and you received the Combat Action Badge for your military service.

You submitted a letter from your squad leader who described an incident in October of 2007 when you were in close proximity of explosions. You submitted another buddy statement from your platoon sergeant that described blast exposures.

Your service treatment records show that you were noted for 2 blasts on July 2, 2008. You were wearing a helmet and in a vehicle at the time and your head was not hit. You did not have a concussion.

VA TBI screening on February 3, 2010 was negative for TBI. On October 7, 2011 you denied a history of TBI or concussion. On October 2, 2013 it was noted that your prior screening was negative for TBI or ongoing post-concussive symptoms. You were noted for a positive screening on October 5, 2013.

At your VA examination on November 5, 2014, it was noted that you were in proximity to multiple blasts during military service. However there was no evidence of altered or loss of consciousness. There was no objective evidence to support a diagnosis of TBI. A full review of the evidence of record was completed by the examiner and it was opined that your claimed condition was less likely than not incurred in or caused by an in-service injury, event, or illness.

The evidence does not show a current diagnosed disability. The VA medical opinion found no link between your diagnosed medical condition and military service. Therefore, service connection is denied.

 

And to the most recent letter from the VA:

We received your claim on November 3, 2015 for TBI/post-concussive syndrome and alcohol abuse (which is considered part of your mental health disability diagnosed as PTSD with major depressive disorder.) We also received your a Notice of Disagreement with the previous denial of your claim for TBI. The recent VA examination results show your PTSD and TBI residuals are intertwined therefore this issue must be addressed by the Appeals team since you submitted a Notice of Disagreement and the TBI and PTSD are intertwined. This rating decision addresses your other claimed issues and your PTSD/TBI issue will be addressed by the Appeals team in a separate decision.

 

 

For the above mention of a TBI screen done in 2010, there is nothing in my notes from the VA that talks about a TBI screen done in 2010. I have everything requested up to the end of last year and have read through them along with my wife and no mention of a TBI screen in 2010. And I don't ever remember making the statement that I denied a history of TBI or concussion on October 7, 2011. And if this was the case, it seems a little odd that I would wait for well over a year from my so called "first TBI screen" to make this statement just to make it. At that time, all my treatment I was receiving had nothing to do with nor did it ever mention TBI.

Also never heard from the Appeals team about the TBI and PTSD being intertwined so I followed up with the 800 number. Turns out the whole claim was closed out and nothing was ever forwarded to the Appeals team. This phone call took place in March of 2016. I received a phone call back from them apologizing for the claim not being forwarded to the Appeals team. They completed a veteran assistance inquiry to determine this and provided me with a reference number for the issue.

A couple weeks later I received another envelope explain I can have either a DRO review or traditional appeals process. My VSO has been sick but another guy that works with him said he would recommend going with the DRO and have them review everything and hopefully reverse the decision and if not recommend that the proper treatment after a positive TBI screen is conducted this time while the claim is pending and make a decision after all that is completed.

 

I think I wrote in all in the best order possible to paint the timeline picture.

 

Edited by ESV12B

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Forgot the evidence list.

VA form 21-526EZ "Fully Developed Claim" received on July 7, 2014, initiated on December 30, 2013.

Service treatment records and service personnel records for period of service from 09/20/2006 to 01/30/2010

Buddy statements received from XXXXXXX and XXXXXXX on July 15, 2014 and August 13, 2014

VA Contract TBI examination on November 5, 2014

Salt Lake City health care treatment records from February 3, 2014 to October 5, 2014.

 

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Obviously this evidence is missing from their decision:

" enrolled in the VA in 2010 and had a TBI screening in 2013 that was positive. I vaguely remember a few questions about what sort of blasts I was exposed to and if I ever was unconscious. The usual questions when discussing TBI. And that was it. They told me I was fine. My TBI screen was negative they said. In 2014 I pulled all my doctor notes from the VA via the Blue Button feature from myhealthyvet. After reading years of notes I read about the TBI screen. There were notes that the TBI screen done in 2013 was positive and that I was asked if I would like to have follow up care and further examinations to determine the severity of TBI if any. The notes specifically said that service member agrees to follow up for positive TBI screen."

Does your VSO have an office in our near the RO building where the DRO is ( or a rep there from their org.)?

"For the above mention of a TBI screen done in 2010, there is nothing in my notes from the VA that talks about a TBI screen done in 2010"

Do you mean there is nothing at all on this TBI screen in your copy of your VA medical records?

I suggest that the VSO ask them to CUE their decision.

They have  committed a clear  and  unmistakable error, to your detriment.

You could make that requst yourself if the VSO does not underastand what I mean.

I will put a link here for this tactic.

 

 

 

 

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I suggest that you print this off for the VSO.

There is no regulation for this tactic. I made it up and it has worked for me. I won the above CUEs (that involved 3 of them I believe,to include the more recent GCY ( Go Cue Yourself VA) request.

I won 2 or 3 more last year.

This is a frontal attack on a decision filed within the appeals deadline. The above CUE request was filed on an award letter.

It doesn't matter if on an award letter or a denial.

If the VA has made a CUE in any decision, to a claimant';s detriment, the way I see it is to get the error corrected ASAP and no better time than when the decision is still ripe.

This type of request should be sent (faxed to the VARO) I can give you their Fax # if they have one, and put  Attention to: on the letter and then use the initials that appear in the alpha numerical code to the upper right hand side of page one of the decision.

I am surprised that they said this would be intertwined with the PTSD claim....as it seemed to me you have stressor proof even without the TBI incident as you were in close proximity to the enemy and have not only the buddy statements but the CAR on your DD 214.

If you tell me the RO name I can give you contact info to get this info and the CUE to them right away...Of course I hope the VSO understands all this

as a bonafide CUE. If they don't, file it yourself.

 

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