Claims denied without C&P Examination

[lotzaspotz]

My husband filed claims in late Jun 2016 for GERD and ED, secondary to meds he's been taking a very long time for service connected disabilities  (pituitary tumor residuals, HTN included in the pituitary residual award, adrenal disorder, and IHD blood thinners).  With his claims, we sent records from his treating non-VA doctors, a list of all his prescriptions, as well as where they're being filled (most from the VAMC here) and Rx number, plus documentation from the online sites for each specific drug that lists the possible side effects.  We found out today via Ebenefits that both were denied and this was done without a C&P exam.  We haven't received the decision yet, so once we get it, then file the NOD, I'll then see about getting IMO's from those same doctors once I can get a look at an SOC.

I'm thinking they screwed up in two ways:  assuming the conditions were strictly age related, and allowing a non-healthcare professional (layperson who was a rater) to evaluate on paper medical conditions.  38 CFR is supposed to prevent either from happening.

This is the first time in 23 years that he's ever been denied without first undergoing a C&P examination.  Have any of you had this happen with your initial claim(s)?  

Edited September 18, 2016 by lotzaspotz

[MarkInTexas]

Lotz,

Yep, I have had that happen before on a few conditions.  NOD'd 'em, regrouped with an IME/IMO and hit them again with an IMO from Dr. Anaise.  I had a C&P last month for all of the conditions this time around.  (Third C&P done so far.). They included all, but the doctor didn't quiz me much on a couple of them.

I'm still waiting, but got my third C-File copy and killed time by going through it.  Found "new" old medical records and tests that the VA hadn't provided to me in previous FOIA's.  You might kill some time by doing a new FOIA for the C-File, and also a request for NPRC documents.  It's like fishing.  You never know what you might catch when you drop a hook!

Meanwhile, I think a good IME/IMO might force their hand.  Others on here have had luck with an IME/IMO pushing the wall over and being granted immediately, but in my own experience, it usually triggers a C&P first.

You're smart waiting for the actual denial to arrive first, because the doctor that does an IME/IMO can shoot at what they are discounting.

Good luck!

Mark

 

Edited September 18, 2016 by MarkInTexas

[Gastone]

Other than for MST/PTSD & Regular PTSD Comp claims, C & P Exams are only requested by the Rating Dept, If the Evidence of Record (Both VA & Private Dr/Hospital) isn't adaquate to Rate the Claim.

You mentioned that you sent in his Private Dr's treatment notes, were any Dr's opinions as to the "At least as or more likely than not," the DX was linked to his SC Condition? Were his private Dr's, Board Certified Specialists or PCP's?

When you get the actual Denial Letter, posting a redacted copy would be very informative to all Hadit members.

[saxman]

Lotzaspotz,  I had the same thing happen to me just last month.  I filed a claim June 2016 for arthritis in my hips secondary to my service connect sarcoidosis.  I'm already secondary service connected for 8 of my major joints from sarcoidosis.  They did a c&p exam when i claim the 8 joints but not when I claim my hips later.  They denied the hips claim.

Edited September 19, 2016 by saxman

[lotzaspotz]

Gastone, both doctors are board certified.  One was a Urologist he started seeing a few months ago, the other a General Practioner who has treated my husband for several years.  The records were of doctors visits, not IMO's, which I'll pursue once I get the SOC and can better target the rationale used to deny without an exam.  We think we met the three pronged requirements of what is needed to file a claim, at least enough to argue that an examination should have been scheduled.

The prescriptions he takes that we focused on were hydrocortisone, livalo, fosinopril, hydrochlorothiazide, metoprolol, and meloxicam.  

 

[Gastone]

I've been doing some reading recently regarding how the VA decides which VA or Contract Dr is going to do the C & P Exam.

C & P Exams, other than PTSD & MST/PTSD, for the most part can generally be handled by just about any Dr MD/OD GP-PCP. Didn't see it mentioned but I would think all other MH claims would also require a minimum of a Psychologist PhD.

All BVA Remands require a MD/DO Board Certified Specialist (MH Psychiatrist) to complete the Exam & DBQ.

I got my initial SA Secondary Award based on the Clinician Notes of my non VA Sleep Specialist Dr, a Board Certified Neurologist. I did have a  discussion with him regarding my understanding of the need for "more likely than not, due to my CAD" to appear in his clinician notes.

All Dr's are different regarding their Clinician Notes but my Dr has always given me a copy of the exam notes as I'm checking out. I would think your husbands Urologist's opinion would carry the most weight. Might be a good idea to get a copy of his treatment notes, see what the Dr has to say.

I was waiting (4yrs on a DRO for ED) when the New DBQ program started. I walked into the VMC Urology Dept, didn't have an appointment. I told the Clerk that I'd like to Drop Off an ED DBQ for completion per VA Regs. He went back, talked to a Dr, about 15 min later the Dr took me to his office. Pulled up my VMC File, completed the DBQ, agreed the Meds were the most likely 50% or greater cause, gave me a copy and faxed a copy to the RO Rating Dept. Within 2 days, the completed DBQ was in my MHV Med Records.

A couple mos later, I actually had the DRO Hearing, decided on Informal. DRO took one look at the ED DBQ, SC Awarded.

Semper Fi

[Buck52]

My PCP OR my MH Providers  refuse to help me with my claims..MH Phyistrist says she don't get involved with veterans claims.End of discussion.

Even took a  Filled out DBQ and pointed out to them on this form where it says to be filled out by your attending Physician 

My PCP says  when I file  for a compensation claim I'll be sent for a C&P they help yuo with your claim..I said Duh  Ok thanks Doc.

I went got IMO That Doc filed it out.