ao Persistant

[Persistant]

Berta told me about Footnote One Nehmer yesterday and I had not heard about that although I do know about Nehmer.  And yes my husband was rated for Ischemic heart disease before it was added to the presumptive list. And his death certificate signed by his GP at VA saying long term heart disease.  It was rated as secondary to diabetes (which was rated 20% initially) and was already a presumptive condition. He had applied for both at that time - about 2003 or 2004.  He was rated 30% initially for his heart even though he had had a quadruple bypass (Dec 2000) with neurological complications, extensive scar tissue from many previous heart attacks that had to be cleaned out before the bypass could proceed in surgery.  He had a TIA on the operating table and post pump syndrome from being on the heart lung machine so long (due to the cleanup) for surgery.  He was told by his heart specialist he could no longer work at what he was skilled to do. He was granted SS Disability as a result 9 months later.  

He filed his first VA claim a couple years later when his buddy finally persuaded him to do it.  He had been diagnosed with Type II Diabetes in 1997.  They didn't address any of the neurological stuff (from the heart surgery) as I recall at all or the post pump syndrome (which usually goes away rather quickly but was a problem for at least a couple years for Don).  The lower left ventricle of his heart was dead already before surgery from previous attacks we didn't know about - silent due to diabetes.  And his ejection fraction was 25 before and right after surgery and then came up to 30-35.  It bounced around some over the years but was usually 30-40. He had an echocardiogram every year which approximated it. After 2 hospitalizations for Congestive Heart Failure over the next few years, they finally rated him 60% heart and 40% diabetes (when he became insulin dependant.  Shortly after starting insulin  - a few months -  Don was put on an insulin pump because he was needing so much insulin and put him on the U500 insulin which is very closely monitored because of being so very strong) and VA rated him for 10% each leg for Peripheral Neuropathy.  Don also claimed PTSD, which should have been granted, as we had a few years worth of records already from a private practice psychologist the VA had recommended whose report said he had it and it was from VietNam (non-combat).  But Va's C&P psychologist or psyciatrist said he wasn't sure of that origin. He agreed Don had it. They asked us to prove Don's stressors.  We searched for months for other guys Don remembered being there, found one but couldn't prove the stressors.  They never contacted us when the requirement to prove stressors was lifted to re-evaluate his claim.

In 2006 they rated  him TDIU and his heart 100% by itself in the same decision with effective dates a few months apart???  Makes no sense to me since the TDIU was then dropped due to the 100% rating.  That was his last rating - 2006. He developed kidney failure late 2010 with a hospitalization of a few weeks for Congestive Heart Failure because the kidneys weren't removing the fluid with normal types of hospital treatment. He was treated by a team consisting of his heart specialist,  his GP who had admitted him, and the new Nephrology group the GP brought in. All Private Practice doctors and hospital. They finally tried something rather bold, I'm told, that started the fluid draining.  After discharge, at home, he had a few weeks of digital monitoring of his stats, reports I had to give them on weight and output amounts etc. and nurse visits and was told to prepare for dialysis.

About that time his doctor at VA called, alarmed, at his rapid decline in kidney function. That is in the medical records at VA along with numerous notations of him being on dialysis and having a port in his abdomen for it, every time he went in for a 6 month checkup.

As you know, Berta, we asked about rating his kidney failure (which his doctors say was from diabetes making it another secondary condition of diabetes and so service connected..) and 3 different VSOs in 3 locations each said we couldn't go above 100%. I didn't know about these kind of forums then.  And only discovered the blog I reference below, by accident.  We also asked his doctors at VA and they didn't know either.  But one of them (unbeknownst to us) requested payment from VA for the 'dialysis treatment plan' and they agreed to pay for supplies, treatment, bi-monthly clinic followups with the 'team' (nephrologist, nurse, dietician, social worker). They also covered delivery of supplies to our home bi-monthly (huge amount of heavy bags of fluid and much more.).  He had started dialysis April 2011 and they began paying April 2013 and continued until his death Dec 6, 2015.  In March 2015 I saw a blog about Special Monthly Compensation and about rating conditions beyond the 100% level. I asked for an analysis of Don's case and the attorney agreed requesting Don's C-File from VA in March. It didn't arrive until late Aug 2015.  The analysis  wasn't quite finished when he died.  A & A was definitely something he qualified for as well and I have many statements from friends, relatives, our pastor etc as well as notes in VA's files and doctor statements about it. But that's another story.

I don't know if Nehmer affects anything I've said here or not.  Does anyone else?  Berta?  And we were not ever contacted by VA or NVLSP about it.  Maybe because he was already 100%? 

I did apply for DIC and Accrued benefits within the year following his death and was granted DIC and denied accrued because they said there weren't any.  They never checked his C file or medical records or Treasury to discover anything really. I had thought the attorney would represent me in an appeal but he's decided not to.

My DIC was granted at the higher level due to Don having been 100% for over 8 years.  I'm not sure what you thought I interpreted wrong about that Berta.  

[Persistant]

The only appeal we ever did was the one you've already seen the DRO decision on.  We simply did what our VSO suggested always...now I see so many issues...one of the big ones was denial of PTSD being service related and there appears to me to be some suspicious stuff surrounding that one involving 2 VA psychiatrists at our local level. So I'm going to leave that one alone due to one of them having seen him monthly the last 4 years of his life and recorded his PTSD as childhood predominantly so I'd never win that one but it is definitely an error at time of decision based on qualified evidence considered and even quoted in the decision. Oh well. Sorry, I'm venting on that one because I lived daily with the issues from PTSD and it was hard.  The other denials included the Post Pump Syndrome and the TIA on the surgery table both of which I judge to be because he was getting operated on for the quadruple bypass in the first place and should be related to that which is rated.  But the decision linked it back to diabetes (which the heart was secondary to) and said they didn't relate. 

No the appeal was for the accrued benefits the original attorney told me I should appeal after a denial and it seemed he would represent me in it but he decided not to I guess.  He never said why or how he was going to justify filing after death just that were many loopholes that could be possibly used. 

The other 2 Nehmer conditions in the 2010 decision I assume don't apply to his conditions or you would have said.  So I will do what you've said about the CUE's and the SMC rating.  I called VVA again and talked to the benefits person and she said I needed to talk to a local VVA rep.  I got voicemail for the closest one to me and left a message. Will I be able to add any evidence to this for the years following the decision to include all the A&A during the dialysis years?  They have records of payment for 2 1/2 years of dialysis to our private provider in their Treasury records and medical records evidence but not the C-File.

Regarding the 160% for the SMC referral - what can substantiate the "adding" as opposed to "combining" to make the argument that they should have done it?

Thank you for the CUE instructions!!!  And for everything you've done for me!!  

[treysnonna]

Persistance, 

did the insulin pump control his diabetes any better.  I'm asking because my husband is diabetic also.  His a1c was 8.2 .  And you said it is a strong insulin.  Did ever drop his sugar really low.  That is how my husbands is up and down.  He also has the kidney failure and ihd.  He has his aortic valve replace.  Had aortic stenosis with it. H  has an appeal in now for the increase in diabetes. And the kidney failure stage.    And we are going to file again for the aortic valve stenosis as soon has I can take new research Dow to his cardiac and get him to agree to it.    They can hear the murmur again with his heart.i sure hate having to deal with va and their slowness.  Good luck to you on your husbands claims etc.  and I'm very sorry for your loss.  It is bad enough for us having to grieve, then fight for everything.  I'm trying to keep everything to gather so I don't have to go digging for papers when I need them.

[Persistant]

Hi Treysnonna,

Yes the insulin pump did help with several things.  He was put on the pump because he needed so much insulin in a day's time that the doctor had put him on 2 kinds and at high amounts...and finally decided he needed something more.  So the pump allowed a continual drip between meals which helped to even out his ups and downs.  Having a more even blood sugar will affect the A1C.  Also the doctor put him on U500 strength insulin.  Now that is something that must be managed expertly so if there isn't someone who specializes in managing it in the pump, don't consider it.  It's very dangerously potent.  And because it is, tiny tiny adjustments in the delivery (the drip or the mealtime doses) can make huge differences. Because of that, it takes a very long time to get it just right around the clock. The pump can be adjusted for different times of the day on the drip and the mealtime doses can also be adjusted as to the strength delivered for each carb you enter for the meal.  You need access to the professional helping to manage it for months by phone as problems do come up, but it is doable and it did really help my husband. He struggled at first learning about it (I learned with him so I could help him) but got pretty good at it over many months.  His A1C was high but I don't recall now how high before the pump.  I do know he managed to get it down to 7.2 though and I think he started in the 8's range. The pump can be used with normal strength insulin too if your husband doesn't need large amounts daily. It's still challenging, but worth the effort.  I don't know if he sees a diabetic specialist, but hopefully he does. He really needs that expert supervision with the problems he has to deal with. We switched from our GP to a specialist when we saw that the GP wasn't able to intervene in every situation and it was a most excellent decision. The specialist has someone on staff who specialized in the pump management and the U500. 

Yes he did have lows both before the pump and with the pump.  I'm sure your husband probably does too.  And you probably have learned how much juice he needs to come back up. My husband needed way more than the doctor said to use, but everyone's different.  We always kept a few bottles of grape juice in the car and of course a lot of it at home where we usually were.  I'm sure your doctor has talked to you both about that though. 

It sounds like you and your husband are on top of the claims and reading this forum, you have access to information we never knew about.  So stay connected here and take note of TDIU and SMC topics because they will relate to your husband's ratings if they don't already.  You don't mention if his heart is rated for anything yet, but the aortic valve replacement surgery can be rated in addition to the IHD (together).  I am not familiar with stenosis, sorry.  Another thought is SS disability if he is unable to work.  Just thoughts.  

I hope this has been helpful and I'm always happy to share any knowledge or experience that can help you.  Is he on dialysis for the kidney failure yet?  That's a whole other subject so feel free to connect with me anytime.  A support group is maybe a helpful thought too.  

Thank you for your sympathy and good wishes!

[treysnonna]

Persistance, thank you for sharing.  He has an appt tomorrow with the.  And I will be looking in to a diabetic specialist.  He is on Lantas solar star U100. And humalog fast acting U100.  His a1c was 8.2.   He takes 75  units of the Lantas solar star a day.

[Persistant]

You're welcome treysnonna...I recognize the insulins your husband is on and my husband was also on Lantus (64 units) U100 (not sure about it being Solar Star or not) and Apidra 14 units + the correction insulin based on the carbs in his meal (2 units for every mg/dL greater than 120).  I haven't any idea how Humalog compares to Apidra though.  His A1C back then was a super good 6.3 after several years of medication balancing.  At that time the notes indicate the doctor was titrating 2 of his meds up to meet lab goals.  This was the dosage in Jan 2007 which was 3 years before he started to use the pump.  If I run across an office visit summary closer in time I'll let you know if you'd like me to as that level did change and so did the A1C. Oh and another reason the doctor put him on the pump was because the U500 was going to be too difficult to measure injections precisely enough, as finite differences could be very important. Also all of the settings for each day were done by the professional overseeing the pump and insulin at each 3 month checkup.  We took care of filling it every few days, inputting the carbs for each meal/significant snack and making sure after that to confirm the pump delivered (the readout says that). We made small changes under her direction, when he was going low too often in one or another part of his day.  Then she'd lower the amount of the drip for that part of the day.That's a great thing about the pump - it is so customizable. You will find that a specialist has many avenues of change to help your husband that the GP probably doesn't know about.  At least that was our experience.

Do you have family or friends who are supportive to you both?  Or someone who has also walked through some of these conditions with their spouse or family member?  As I mentioned before, a support group is also helpful...you both have walked through a lot with the conditions he has and may be able to help others as well as they being able to help you.  Sometimes just attention to all the requirements for his conditions takes up so much time & tension that it keeps you separated from others, but purpose to stay connected to others, whether on the phone, email, a quick coke together or whatever.... It helps.  

Have a great rest of your day and evening! 

[Persistant]

Berta you had asked to see the decision for the PN claim.  I'm attaching it here.  I may be wrong but I think there are some CUEs in this one...

Under Reasons for Decision:

There are 9 conditions being considered.  All of them were tested against whether or not they developed during service or a prior condition worsened in service or was it caused by diabetes.  In regard to the stroke occuring during open heart surgery, their statements conflict with each other seems to me.  And they lumped stroke with post pump syndrome which does not compute in my mind...they are not both strokes I don't think.  In the beginning it says sc could be granted ....but is denied  because it didn't occur during service or caused to worsen by service.  Then it says there's no evidence of residuals from it.  WOW - wrong!  They then talk about sc on a presumptive basis if manifested to a compensable degree 38CFR 3.309(a) and 3.307 and then say the evidence shows that it is currently disabling to a compensable degree but evidence shows it didn't happen within one year of discharge so must be denied.  Does that all sound right?   

Then the IHD narrative...my underlined sentences are in conflict with one another and the higher rating it referrs to is proven and met, but not granted.  

Also, what about this...IHD became presumptive a few years later but they never made the IHD a primary condition - it remained a secondary condition.  Doesn't that make it impossible to rate the stroke and post pump syndrome as caused by the IHD?  So not changing it to primary caused 2 conditions that were denied to stay denied?  Weren't they supposed to go back to all claimants of IHD and update the status?  Maybe I have misunderstood, I'm not sure. 

Under PN they say no nail abnormalities in either foot which isn't true and we submitted the records from his foot doctor to show the history of nail fungus from VietNam.  It eventually caused the removal of both big toenails and some of the secondary toenails were as thick as they were long from the cuticle to the tip and couldn't be cut  except in the doctor's office.  I don't think I saw those records in the C-File but we submitted them and I have them.  Now the question would be does that change the rating any...I would guess not.

I haven't seen a listing of conditions after the 100% yet (in my paperwork) to know about the PN combination you suspected.  I will look tonight in the C-File

Scan0026.pdf