Process for Requesting Increase w/o DBQ

[glarus]

Bottom line up front: I am requesting an increase for my shoulders based on limited range of motion, now rated at 10% each. Range of motion testing using a goniometer isn't something doctors do for diagnosis and treatment , so I don't have the medical documentation to make this a simple, fully-developed claim. Should I submit the request with no supporting documentation and await a C&P, or try to find a physician who would see me to document the limited ROM?

I have an orthopedic surgeon (and another where I used to live,) but as many of us know, our doctors' concern and job is treating our problems, not participating in administrative processes. Going to see him because I feel terrible and then asking, "oh by the way, can you help me with this form?" seems like it would be awkward and like the real reason I'm there. It's not. Documentation of injuries and attribution to specific events, times, etc. (in line with the notion of a C&P exam being not at all about treatment,) seems to be a niche field, and not handled by many physicians. But that's just an impression I now have. For all I know, lawyers who handle SSDI claims have Rolodexes full of these guys. My own experience, and what I've read here, certainly suggests it's a widespread problem among VA (and SSDI?) claimants.* I have added a bit more detail below, but in short, the issue is documenting reduced range of motion.**

 

I am rated 10% for each of my shoulders, based on different VA-recognized conditions. Because the rather limited list of conditions in the schedule doesn't include my issues, they are both rated as:

5003    Arthritis, degenerative (hypertrophic or osteoarthritis)

When I claimed the conditions, I could abduct my arms higher than shoulder level (I think to 120 degrees, with normal being 180.) I have long been unable to abduct my left arm to shoulder level (to 90 degrees.) Now, I meet the criterion under this section: 

5201    Arm, limitation of motion of:

Midway between side and shoulder level      30 (major)        20 (minor)

At shoulder level         20        20

Abduction on the left side ("major," as I am left-handed,) is permanently limited to well below the shoulder, and on my best days, the right side ("minor") may reach shoulder height. Good day or bad, it's 30 and 20.

* I do not use the VA for my care, but it seems those of you who do have the same problem. The "claims" aspect of medicine is one they treat like it's radioactive. Getting an IMO or DBQ involves paying out of pocket or being fortunate enough to have a close relationship with a rare and special care provider.

** I guess a potential question is whether it's due to the S/C conditions, but I don't think it will be a problem. For the left side, VA only lists acromioclavicular (AC) joint degeneration, but the first MRI was done in-service, and the second was done in conjunction with a C&P. The readout for both diagnosed damage to both the AC and glenohumeral joints. The right side has not been imaged by MRI, but I am S/C for rotator cuff tendinopathy (a glenohumeral joint condition.) It was diagnosed in service, and diagnosed and treated post-service. If VA said left side limitation is not due to AC joint degeneration but a glenohumeral joint condition, I would just say OK, call it a new claim if you want, but glenohumeral joint damage is documented in the SMR and in VA's prior decision, and the compensable condition is "limitation of motion."

Edited March 30, 2018 by glarus

[Buck52]

If you need medical documentation to prove as evidence  yes go see a specialist for an IMO/IME and ask they use the goniometer to measure ROM and go into details about your pain ect,,ect,,be sure the Dr is qualified and state license, read up on the CFR/s about your disability and the requirements for rating purposes  so you can add that into your claim. 

https://www.hadit.com/c-and-p-rom-test/

[broncovet]

You posted,

Quote

 Going to see him because I feel terrible and then asking, "oh by the way, can you help me with this form?" 

Frankly, you need to get over this, and ask him.  You wont be getting benefits unless its documented.  Yea, you could use a VA doc instead, but the bottom line is it needs to be documented.  "Ignoring" the gorilla in the room does not make him go away.  In the military, we were told to "suck it up", and just push past the pain.  

Neither doctors nor VA personel are clairvoyant.  If you want the benefits you deserve, you have to describe the symptoms to your doctor, and ensure they are well documented.  

To answer your question, we normally use VA docs first, then use an IMO/IME only when VA docs wont supply us with a necessary nexus.  We do it that way because VA medical care is generally free to Vets, while we often have to pay copays and deductables even with insurance.  Insurance "almost certainly" wont pay for an IMO/IME to get VA benefits.  "No cost" is better than some cost, for most people.  

I completely understand, however, not wanting to use VA for multiple reasons.  Remember, VA requires a documentation of your symptoms and not a C and P exam.  C and p exams are ordered only when there is medical documentation lacking.  If you already have the documentation, a C and P exam "should" not be necessary, provided that you "make sure" VA has your private medical records.  (That is, mail them to the intake evidence center, certified mail return receipt requested).  

   My advice:  Apply for the increase, and talk to your doc about documenting your increased symptoms.  Dont feel bad about getting the benefits you earned in service.  

   IMPORTANT:  Dont ignore the Service connected issue as VA wont.  Make sure you have 1) current diagnosis 2) in service event or aggravation and 3) nexuss in the proper form VA will require.  Many private physicians dont know what Va is looking for, and dont do a great job in documentation for sc purposes. 

    If this is an "increase", then you already have sc documented, you need only document your worsenting condition since the date of the exam to which Va used to award your benefits initially.  

    However, if this is a "new condition" or secondary condition, you need to have an applicable nexus.  

[vetquest]

I agree with Broncovet on this.  Ask your VA provider.

An IME/IMO is hard to get on the outside.  Most doctors do not want to become involved and ones that are willing to cost one to several thousand dollars.

[glarus]

Thank you the advice. Since I'm seeing the orthopedic surgeon now for it (and got a steroid injection in the left AC joint recently, without relief,) I think it will be less awkward to ask at the next appointment. I saw the CBOC GP once after enrolling with the VA health system. She was nice and I would have no qualms about having her as my physician, but I saw no reason to switch doctors. Continuity of care is very important, especially when you have chronic or episodic symptoms with no diagnosis, or something is chronic and needs to be seen in that context.

(Off on a tangent,) I'm fortunate to have other coverage through my employer, because the VAMC is 83 miles from my house and 70+ miles past both my local major university medical center and an excellent community hospital system which offers the full range of medical services. My town is a place people from all over the region drive to for excellent healthcare, not away from. I think how we see the VA medical system is a matter of perspective. My boss is retired military and thinks nothing of driving to the VAMC, which is over 90 miles from his house. Military and VA healthcare is all he ever had, and he thinks the VA is great. I was in the healthcare industry before military (medical) service, and I see patients as customers, with freedom of choice and the right to seek a level of service they find acceptable, things not found in state-run, "take it or leave it" medical systems. The idea of taking a day off from work and putting 150 miles on my (frustratingly unreliable) car for an x-ray is a non-starter in a first world country, especially in a town where I can throw a stone in any direction and have a good chance of hitting a doctor's office. No veteran should have to drive past top-rated providers of the services he or she needs. We should all have access to the full range of excellent, local (or for rural veterans, the closest,) health services. 

Edited March 30, 2018 by glarus

[broncovet]

Feel free to use either VAMC or private care, your choice.  To reiterate, your private care doc is unlikey to know about va requirements for a nexus.   

If this is for a NEW CONDITION or secondary, then you need a valid nexus statement from your doc.  

If this is for a increase (worsening of symptoms) then you need only document that your symptoms are worse...you dont need a nexus when its already been sc.  

[Navy04]

Surprisingly the last 2 DBQs have been filled out easily by Civilian and VA Docs, caught me off guard. I feel for your shoulder and I have a torn cup and nerve damage. I will get around to the surgery one of these days when the other stuff quiets down. As far as ROM and Painful moving, I feel that the VA Screws too many veterans. Hell I have had 2 knee surgeries on the right, and need surgery on the left, and yet both are rated only 10%. I feel that the C&P Docs try to force Vets to do movements that they shouldnt, then use it as evidence against the Veteran. A Vet should always put in for an increase in SC if it has gotten worse, and never be scared or ashamed to ask a doc to fill out a DBQ, even though most wont. GOod luck and keep us posted. God Bless