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MKAH

Calim is now listed as Prep for Decision & I never had a C&P

Question

Good morning,

Just last week I completed an eight week out of state PTSD residential program. 

Long story short, I have a combination claim filed since November 10th, 2016 for PTSD-MST (new) & Hearing Loss (increase).

A recent VA Audiology re-evaluation by my local VA clinic appeared in MHV notes as a DBQ for my current claim and was counter signed by an audiologist (AU). :

*************************
Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
    Request?
    [X] Yes   [ ] No ****
    ACE and Evidence Review
    -----------------------
    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
    ---------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS
 1. Objective Findings
    ---------------------
    a. Puretone thresholds in decibels (air conduction):
    
                                    RIGHT EAR
    +==============================================================+
    |    A   |    B   |    C   |    D   |    E   |    F   |    G   |
    |========+========+========+========+========+========+========+========+
    |   500  |  1000  |  2000  |  3000  |  4000  |  6000  |  8000  | Avg Hz |
    |   Hz*  |   Hz   |   Hz   |   Hz   |   Hz   |   Hz   |   Hz   | (B-E)**|
    |========+========+========+========+========+========+========+========|
    |    30  |    50  |    75  |    85  |    95  |  105+  |  100+  |    76  |
    +=======================================================================+

                                    LEFT EAR
    +==============================================================+
    |    A   |    B   |    C   |    D   |    E   |    F   |    G   |
    |========+========+========+========+========+========+========+========+
    |   500  |  1000  |  2000  |  3000  |  4000  |  6000  |  8000  | Avg Hz |
    |   Hz*  |   Hz   |   Hz   |   Hz   |   Hz   |   Hz   |   Hz   | (B-E)**|
    |========+========+========+========+========+========+========+========|
    |    35  |    50  |    70  |    80  |    85  |  105+  |  100+  |    71  |
    +=======================================================================+
    
    b. Were there one or more frequency(ies) that could not be tested: No

    c. Validity of puretone test results: Test results are valid for rating
    purposes.

    d. Speech Discrimination Score (Maryland CNC word list):
       +=======================+
       |  RIGHT EAR  |    56%  |
       |=============+=========|
       |  LEFT EAR   |    56%  |
       +=======================+

*****************  The audiological reports looks fine to me. 

Since November 2014, I have had extensive treatment by four different VA Clinical Psychiatrists, as well as many NP's and of course many LSW's in treament of my PTSD-MST.  Treatment has ranged from medications, two separate (week long inpatient admissions to BH-ICU's) in both California and Oregon.   EMDR treatment, Progressive Exposure Therapy treatment at a residential facility for eight weeks, as well as MANY MANY other VA PTSD treatment classes. 

I am now scheduled to fly back east in September for PTSD-MST specific treatment as my treating psychiatrist is believes that I need additional specific MST treatment as she an the other VA doctors describe as Chronic and Severe.   In a nut shell, everyone, including the doctors and staff at the VA have been working there butts off to make progress in my treatment, but I continue to require more treatments in a PTSD-MST specific facility this coming September.  I currently have about 600 pages of VA PTSD related notes in my blue button download report.

 

QUESTION: Anyway, my questions is; My claim has recently been moved from collecting evidence to prep for decision and I have not had or been scheduled for a C&P exam for PTSD-MST.  

Do C&P exams always need to happen for claims to be decided or rated?

 

Thanks in advance

 

 

 

 

 

 

 

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A C&P is not required if they think they already have enough evidence without it.  Your claim could also return to the evidence collecting stage and they could order for one before it is all over.

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