Nod, SOC and form 9 done - resulted in C&P

[toomnyhats]

I am 60% for neurogenic bladder, 10% for tinnitus.  I'm a C3 Quad ASIA C due to a pre-existing condition of narrow cervical spinal canal.  First attempt for spine connection failed.  Requested De Novo Review..same results. Filed NOD and Form 9.  Then sent in a great IMO from a very reputable specialist.  This, along with a letter from my VA SCI physician seems to have triggered a C&P exam for neck and back.  

The exact services ordered were:  DBQ MUSC Neck (Cervical Spine)(1), DBQ MUSC Back (Thoracolumbar Spine)(1), DBQ Medical Opinion - MED: MUSC Back (Thoracolumbar Spine)(1), Med - Medical Records/Cfile Review - FILL FIRST (1), CPT 99205 - Level 5 E/M, new patient (60 minutes) (1), CPT 99090 - Analysis of clinical data stored in computer (Claim File) (1)

The physician seemed very thorough but throughout the exam/interview, she said several times that the VA had connected my cervical spine.  I wasn't quite sure how to take that.  Then I really looked at the services ordered above and noticed that they ordered a Medical opinion on my thoracolumbar spine but not on my cervical spine.

Is it a leap to think she might be right and the reason they didn't order a Medical opinion on the cervical spine is that they only needed the exam (ROM measurements, function, etc) for assigning ratings?

Any opinions greatly appreciated!

 

Edited April 25, 2018 by toomnyhats

[pwrslm]

I dont think anyone can answer this without access to your CFile at this time. The RO may have enough info to SC your cervical spine, but needs info on the Thoracolumbar and a medical opinion. If the Examiner gave a neg report on that, you may not get SC on it, but you can still get an IMO/IME to contradict a negative opinion. When your Ebenefits acct shows that your in prep for notification, it will be too late to submit any more info, so dont wait if you dont already have an IMO on the NEXUS for what they want opinions on.

CPT 99090 is just review of records, so they do want a thorough check done by the examiner regarding your medical records.

CPT 99205 is A comprehensive history; A comprehensive examination; Medical decision making of high complexity.

[toomnyhats]

Thanks pwrslm!  I was wondering what the CPT codes were.  Being a C3 quad ASIA C, makes the cervical neck issue the biggie.  That is what was most addressed in my VA docs letter along with my IMO.  Both agreed that it was more likely than not related to service.  The IMO didn't get submitted until after the form 9 so that obviously triggered another review and subsequent C&P.  The doc said at least 3 times that the VA had already connected my cervical neck which might explain why they didn't ask for a medical opinion on it (since they have two already).  If we can connect cervical spine...secondaries will cascade explosively given all the surgeries and complications I've had.

toomnyhats