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lotzaspotz

Baseline GERD question on DBQ Form

Question

Good morning, all.  Can someone tell me where the DBQ for GERD asks about a baseline level of GERD?  My husband's treating private physicians, one a GP and the other a gastrointestinal Board certified specialist, both completed DBQ's.  The claim was denied solely because they both did not describe a baseline level of GERD, but I don't see that question on the form.  That appears to be the only reason it was denied.  The VA had release of information letters for the doctors, but we provided copies of all the records ourselves.  I don't know why, if that one isolated piece of information was missing, the VA didn't let the doctors or my husband know (we could have addressed that prior to a denial).  Plus, there was no C& P exam provided.  We thought this might have been an oversight, but it wasn't, the denial without a rating exam was repeated by the DRO.  The claim regarded certain medications taken for service connected conditions for many years that have a clinical connection to causing GERD, as the doctors reported.

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Do you think this might be why they asked about "baseline"?

https://www.ecfr.gov/cgi-bin/retrieveECFR?n=se38.1.3_1310

Quote

§3.310   Disabilities that are proximately due to, or aggravated by, service-connected disease or injury.

(a) General. Except as provided in §3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.

(b) Aggravation of nonservice-connected disabilities. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level.

(Authority: 38 U.S.C. 1110 and 1131)

(c) Cardiovascular disease. Ischemic heart disease or other cardiovascular disease developing in a veteran who has a service-connected amputation of one lower extremity at or above the knee or service-connected amputations of both lower extremities at or above the ankles, shall be held to be the proximate result of the service-connected amputation or amputations.

(d) Traumatic brain injury. (1) In a veteran who has a service-connected traumatic brain injury, the following shall be held to be the proximate result of the service-connected traumatic brain injury (TBI), in the absence of clear evidence to the contrary:

(i) Parkinsonism, including Parkinson's disease, following moderate or severe TBI;

(ii) Unprovoked seizures following moderate or severe TBI;

(iii) Dementias of the following types: presenile dementia of the Alzheimer type, frontotemporal dementia, and dementia with Lewy bodies, if manifest within 15 years following moderate or severe TBI;

(iv) Depression if manifest within 3 years of moderate or severe TBI, or within 12 months of mild TBI; or

(v) Diseases of hormone deficiency that result from hypothalamo-pituitary changes if manifest within 12 months of moderate or severe TBI.

(2) Neither the severity levels nor the time limits in paragraph (d)(1) of this section preclude a finding of service connection for conditions shown by evidence to be proximately due to service-connected TBI. If a claim does not meet the requirements of paragraph (d)(1) with respect to the time of manifestation or the severity of the TBI, or both, VA will develop and decide the claim under generally applicable principles of service connection without regard to paragraph (d)(1).

(3)(i) For purposes of this section VA will use the following table for determining the severity of a TBI:

Mild Moderate Severe
Normal structural imaging Normal or abnormal structural imaging Normal or abnormal structural imaging.
LOC = 0-30 min LOC > 30 min and < 24 hours LOC > 24 hrs.
AOC = a moment up to 24 hrs AOC > 24 hours. Severity based on other criteria.
PTA = 0-1 day PTA > 1 and < 7 days PTA > 7 days.
GCS = 13-15 GCS = 9-12 GCS = 3-8.

Note: The factors considered are:

Structural imaging of the brain.

LOC—Loss of consciousness.

AOC—Alteration of consciousness/mental state.

PTA—Post-traumatic amnesia.

GCS—Glasgow Coma Scale. (For purposes of injury stratification, the Glasgow Coma Scale is measured at or after 24 hours.)

(ii) The determination of the severity level under this paragraph is based on the TBI symptoms at the time of injury or shortly thereafter, rather than the current level of functioning. VA will not require that the TBI meet all the criteria listed under a certain severity level in order to classify the TBI at that severity level. If a TBI meets the criteria in more than one category of severity, then VA will rank the TBI at the highest level in which a criterion is met, except where the qualifying criterion is the same at both levels.

(Authority: 38 U.S.C. 501, 1110 and 1131)

[44 FR 50340, Aug. 28, 1979, as amended at 66 FR 18198, Apr. 6, 2001; 71 FR 52747, Sept. 7, 2006; 78 FR 76208, Dec. 17, 2013]

 

 

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I don't know, but I figured if that was information the VA needed to make a rating decision, they would have included it on the DBQ for GERD.  If it's not there for the non-VA doctor to answer, it wouldn't be there for the C&P examiner to answer, either.  Only, there was no C&P exam offered, despite the DBQ's by treating MD's and evidence of prescriptions taken to treat SC conditions over the course of several years.  

 

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I agree with you Lotz, its just the VA's BS for Denials. 

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