Which is More Effective: DBQ or IME/IMO?

[FlyHigh1995]

I've recently come to the conclusion that I will have to seek second opinions from medical professionals with either DBQs or IMEs/IMOs. After submitting a FOIA request to see what C&P physician put in my file; I noticed most of what I told her was not in record and some things she claimed she did during my physical  exam...she never actually did. I have been contacted by many IME doctors that are willing to give a second opinion. I would appreciate if anyone could give their experience as to which is better regarding a DBQ or IME/IMO. 

[Berta]

Even without having an attorney, strong DBQs and/or IMO/IMEs can make Our jobs easier as claimants.

But that often means we have already done a lot of leg work and have determined that a costly IMO/IME will make our claim succeed.

When I stated this yesterday:

"My actual FTCA wrongful death case was easier than this claim was-but that was out of the hands of the RO I deal with."....

what I meant was that VA attorneys, whether at OGC or the BVA -like ALL attorneys, LOVE evidence...and they (unlike our ROs) are willing to read Everything!  Once a claimant gets a strong IMO /IME , and sends it to the VA, they only have one thing left to do, hope for and pray that someone at the VA reads and understands it.

 

 

 

 

[acesup]

As always, great advice here to address a tricky subject.  The easy answer to which evidence is better would be the evidence that will best likely support your claim, but most claims aren't simple enough to say either DBQ or IMO/IME is better.

IMHO, if a claim is for a common condition with commonly known and accepted logic that should get service connection, I'd think a DBQ is probably going to get the job done.  Problem is, few claims are that cut and dried.

In my own recently-granted (by BVA) claim, I had several issues that absolutely would have died with a plain DBQ.  If a condition needs much in the way of a Nexus, or has some unusual circumstances to warrant SC, whether direct, secondary, or aggravation, an IMO/IME or Nexus letter with supporting evidence will get you there.

For instance, before I filed my current claim in 2009, I  was rated 50% overall:  40% for lumbar spine injuries, 10% for residuals of Hep B.  (Both SC since I got out of the Air Force in 1974),   I had several VSOs and "knowledgeable" vets, and even at least one career VA rater/DRO,  tell me I would never get SC for  the issues I was pursuing, including Major Depressive Order, Obstructive Sleep Apnea, residuals of DVT/PE (chronic thromboembolism), convulsive tic, C-spine injuries, upper extremity neuropathy, sciatica, migraines, and TDIU.  

I sought out specialists, none of whom are usually considered "IMO/IME doctors" like you'll find on these sites.  I saw a sleep specialist Pulmonary M.D. and my civilian PCP to discuss connecting the dots between my SC back and meds and pain and lifestyle, etc. to OSA.  I brought them my SMR and civilian medical records,  evidence of meds' well-known side effects, anything I could find that supported any links, and after these visits, I went home and drafted Nexus letter with the key phraseology included, each letter having options for doctor to choose between "is due to", "more likely than not likely", "as likely as not likely", "not as likely as not likely", and "is not due to".

When I came back for follow-up visits, I brought the draft letters in my hand.  I would get the doc to discuss the talk we had the previous visit.  I would then bring out the letter, and ask him if he agreed with the logic.

I did the same with two experts on DVT/PE, with convulsive tic, with everything except the depression.  Great thing is, the VA Psych who did my depression C&P told me that day that my depression had been present since 1973-1974 active duty, and I figured I didn't need any other opinion on that issue.  (I didn't, either).

I only had one doctor who refused to help, a weird Neurologist.  (I was always kind of nervous around him anyhow, he looked/acted like he might strap on an exploding backpack at any moment)  LOL

In my experience, the best source of docs who would help with opinions are in the University med schools and hospitals.  One of my experts was a head of Thoracic Surgery and a longtime top professor at such a school/hospital.

Here's the challenge:  being able to carry on an informed, intelligent conversation with a doctor, without making an ass of yourself OR him.  And there probably is no competent doctor who would just blindly sign a paper saying "Mr. X's OSA is caused by his bad back."  There HAS to be logical evidence to support a Nexus or any medical opinion.  No doc is going to risk his reputation and face ridicule for a signing onto a preposterous, unsupported theory.  Not to mention that the VSR at your VARO would add the letter to the office joke pool to pass around and give everyone a good laugh.  It is YOUR job to amass that evidence, if it exists, then ask the doctor his opinion on your theory.  And if you're wrong, you will possibly learn how and why you're wrong, and maybe even how you might go back and get it right.

BTW, the recent BVA award I won was incredible.  All but sciatica and migraines were granted, and they're remanded for fairly minor issues, I think when the dust clears I will get them granted too, even though they don't matter anymore.

Best of luck in achieving the ratings you deserve!

[Berta]

Thank you for that excellent reply to this topic.

I know of a few vets over the years, who felt a costly IMO/IME would establish a nexus to their service- yet they really had no nexus...very few vets would do something like that....and you are Correct that no doctor would be willing to state anything illogical or  medically unfounded.

This is a great idea:

"In my experience, the best source of docs who would help with opinions are in the University med schools and hospitals.  One of my experts was a head of Thoracic Surgery and a longtime top professor at such a school/hospital."

I was reminded of this- a little off track but anyhow-

Long long ago I had a vet whose 100% P & T was threatened by a proposed reduction.After being SCed for AO NHL for years the RO said they determined he did not have Boots on Ground -Vietnam.

He was willing to be proactive and had a strong statement from an English professor ,that challenged the way the regulations were worded.This was when NHL regs were being played around with by the VA- Many years ago.

I thought the college  Professor's statement was very impressive.But another incident the vet recalled, after many phone calls we had-did the trick- he only had one Boot on ground Vietnam, could prove it ,and that was all he needed.VA cancelled the hearing he requested and dropped the proposed reduction.

VA is a War of the Words, and we have to get the best evidence we can, where-ever it comes from.

I never considered getting a statement from any college professor to fight a claim-but I did consider sending my RO  copies of "Reading For Dummies" a few times.

I do think the lack of literacy was often a reason for many of my denials....that turned into awards when someone actually read my evidence.

 

 

 

 

 

 

 

[vetquest]

I believe IMO's are gold in the VA process.  While I have had little luck with the RO I have had great luck with BVA.  I was service connected for a neuropathy twenty five years after the fact when a doctor wrote an IMO that showed a nexus with injuries I suffered in the military.  He cited contemporary literature.  I provided a letter from the Secretary of the VA that stated the my injuries could cause neurological consequences.  A good doctor that knows how to write what the VA needs to service connect is well worth it. 

[FlyHigh1995]

I really appreciate you all taking the time to share your experiences and knowledge. I  wish I had this information years ago!  Getting benefits and services is most certainly challenging.  My claim consists of conditions that are clearly in service records in black & white and I’m still denied service connection and trying to increase current ratings due to conditions worsening. From the information shared seems like an IMO is the best option (especially for more complex medical conditions) but depending on condition...a DBQ may suffice i.e. GERD.  I can see how verbiage is definitely key when getting VA benefits. After being denied three times by a counselor at VA VocRehab ... I finally was offered benefits only after I emailed him ( to document communication) using CFR VocRehab regulation verbiage regarding what I may be entitled to as a disabled veteran. It was like bargaining and negotiating at a car dealership...lol.

[Berta]

You stated:

"My claim consists of conditions that are clearly in service records in black & white and I’m still denied service connection and trying to increase current ratings due to conditions worsening."

Did you at any point copy those SMR pages holding the entries, and highlight them and them send them to VA in Support of the claims?

I feel that it takes a doctor- not a rater, to be able to actually read SMRs and I think VA often just  skims over them.

I had a vet, twice at CAVC, denied from the git go for years, - my former dumb vet rep asked me to help him.

Not only did I discover his lawyers never even read his BVA case well (it held a big clue in their last denial) but also No one ever read his SMRs well.

These were handwritten SMRS very difficult to decifer but I found enough in them to copy, highlight and decifer to help him finally win his claim. VA heldback quite a chunk for his lawyers but I followed a 5 point regulation I found,  or maybe the regulation  came with their letter to him on the legal fees)whereby a vet can challenge a legal fee, so I prepared that, and stated that as an unpaid veteran's advocate, I was the only entity who had actually read his SMRs and my findings supported an IMO he got. I arfued over all 5 of the cndityions in the regulation.I never heard back from him so I assume that letter and the evidence I sent with it, proved to VA these lawyers did Nothing to help him.

I have had to spell out to the VA, like they are 10 years old, my issues-at times.

I received a payment based on an "estimated" Nehmer audit, that no one checked at my RO and this holds a major financial error. I filed CUEs on it and referred them to the legal evidence that supports those claims.

I made sure I sent to them many pages from the Nehmer award, highlighted and  sent my legal evidence 

for each CUE issue and a copy of my own calculations.I also sent them pages from 2 of their decisions.

And testified as to the truth of their Director's ridiculous phone calls to me.

My long point here is that we have to clarify not only our issues but also whatever evidence they need for support.

These are CUE claims, so that means the medical evidence has to have been established with VA prior to the decisions being Cued. They have that evidence.They have had it for years and got it again 2 years ago.

I not only highlighted a OGC Pres Op for them, I also had to explain to them the Nehmer Court Order for one CUE claim.And enclosed an email from the Head AO Attorney at NVLSP .

My long point here is, even if they have SMRS and any other evidence to support our claims, that does not mean they will properly read it right off the bat and consider it in their decision.

I also used violation of 38 CFR 4.6 for the 4 or 5 CUEs I filed this past month- it is my favorite regulation.

I used it this way in my first two CUEs in August:

"The second CUE (2)lies in the statement of “combined rating for accrued purposes remained at 100%” in the second page of the March 6, 2015 decision.

The veteran was rated at 100% P & T for SC PTSD with an EED (Earliest Effective Date) of November 1, 1991. ( a posthumous award)1997

The veteran was also ratable at 100% P & T under Section 1151, 38 USC, from August 9, 1992 to October 14, 1994 by evidence confirmed by John Wagner, Buffalo VARO on February 19, 2018, yet the evidence was never considered .

 

That is a violation of 38 CFR 4.6:

§ 4.6 Evaluation of evidence.

The element of the weight to be accorded the character of the veteran's service is but one factor entering into the considerations of the rating boards in arriving at determinations of the evaluation of disability. Every element in any way affecting the probative value to be assigned to the evidence in each individual claim must be thoroughly and conscientiously studied by each member of the rating board in the light of the established policies of the Department of Veterans Affairs to the end that decisions will be equitable and just as contemplated by the requirements of the law. Exhibit  "

I also filed CUE on 2 phone calls from my RO Director,under 38 CFR 4.6 and the fact that she apparently does not know VA case law.

We cannot assume we will get whatever Duty to Assist means nor can we assume the VA will read our evidence " thoroughly and conscientiously" (38 CFR 4.6)

 

 

 

Edited September 27, 2018 by Berta