Jump to content
  • Advertisemnt

  • 14 Questions about VA Disability Compensation Benefits Claims

    questions-001@3x.png

    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
    Continue Reading
     
  • Donation Box

    Please donate to support the community.
    We appreciate all donations!
  • Ads

  • Most Common VA Disabilities Claimed for Compensation:   

    tinnitus-005.pngptsd-005.pnglumbosacral-005.pngscars-005.pnglimitation-flexion-knee-005.pngdiabetes-005.pnglimitation-motion-ankle-005.pngparalysis-005.pngdegenerative-arthitis-spine-005.pngtbi-traumatic-brain-injury-005.png

  • Advertisemnt

  • Advertisemnt

  • Ads

  • Can a 100 percent Disabled Veteran Work and Earn an Income?

    employment 2.jpeg

    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

  • Searches Community Forums, Blog and more

  • Ad Free Subscription.jpgOne Time Financial Gift.jpg

    Subscriptions and Gifts are NOT Tax Deductible. HadIt.com is NOT a Non Profit.

  • 0
ArmyMajor

C and P Exam PTSD/MST More Information

Question

 

I have included all of the information to include the opinions of three different VA psychologist/psychiatrist, clinical nurse practitioner and therapist opinions.  The clinical nurse practitioner most recent diagnosis was chronic PTSD and depressive disorder by psychiatrist, medical doctor (April 2018)

 

Therapist Notes (December 2018)


PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month.

 PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks.

 PHQ-2+I9 Suicide Screening Score: 1  The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9).

 

Posted March 24, 2018 (edited)

 

I was scheduled for an appointment with a VA psychologist and the below are her results, which is seems to conflict the C and P examiner ...... any feedback is appreciated

 VA Psychologist Notes (March 2018)

Military History

Branch (years of service): MST: yes
 

MEASUREMENT BASED CARE:
PHQ-9: 19 (moderate)
GAD-7: 16 (severe)
PCL-5:
AUDIT-C: 5 (above threshold)

 

DIAGNOSTIC IMPRESSIONS:
Anxiety Disorder, unsp
MDD, recurrent, moderate

 

Depression Monitoring (PHQ-9) 2017:
Depression Screen:
PHQ9 Screening
PHQ-9
A PHQ-9 screen was performed. The score was 19 which is suggestive
of moderately severe depression.

 

PTSD Screening:
PTSD Screen:
PTSD Screening
PC PTSD
A PTSD screening test (PC-PTSD) was positive (score=4).

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

C & P Examiners Notes (March 2018)

 

SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
If no diagnosis of PTSD, check all that apply:
[X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under
DSM-5 criteria
[X] Veteran has another Mental Disorder diagnosis. Continue to complete
this Questionnaire and/or the Eating Disorder Questionnaire:
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: UNSPECIFIED DEPRESSIVE DISORDER
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): SEE MEDICAL CHART
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
4. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Occupational and social impairment due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication

TYPE OF MEDICAL OPINION REQUESTED: Military Sexual Trauma (MST)
OPINION: Military Sexual Trauma (MST)
This examination is being conducted to assist with determining whether the
Veteran experienced an in-service personal assault stressor related to
military sexual trauma (MST) that has resulted in a current PTSD diagnosis.
Please review the claims file and state in your report that it was reviewed.
In your review of the claims file, please pay special attention to signs,
events, or circumstances that may represent markers for the MST stressor
described by the Veteran. Your review is not limited to the evidence
identified on this request form, or tabbed in the claims folder. If
additional testing is required, please obtain it prior to rendering your
opinion.
Based upon your review of the evidence, please provide a medical opinion as
to whether the MST stressor event described by the Veteran is at least as
likely as not (50 percent or greater probability) supported by and consistent
with the in-service marker evidence. Please provide a rationale for the
opinion and list the marker evidence used to arrive at your decision.
NO MARKERS IDENTIFIED. MEDICAL OPINION DOES NOT APPEAR WARRANTED.


In addition:
1. IF YOUR EXAMINATION DETERMINES THE VETERAN HAS A CURRENT DIAGNOSIS OF
PTSD, please provide an opinion as to whether the current PTSD diagnosis is
at least as likely as not (50 percent or greater probability) caused by or a
result of the in-service MST-related marker(s), and provide a rationale.
Please note that only PTSD can be service connected based on circumstantial
marker evidence (38 CFR 3.304(f) (5)).
VETERAN'S SYMPTOMS APPEAR TO BE BEST ACCOUNTED FOR BY A DIAGNOSIS OF
UNSPECIFIED DEPRESSIVE DISORDER. MEDICAL OPINION DOES NOT APPEAR WARRANTED.

2. IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS
ADDITIONAL MENTAL DISORDERS, please state whether the additional mental
disorders are at least as likely as not (50 percent or greater probability)
secondary to the PTSD, and provide a rationale. For each mental disorder

MEDICAL OPINION DOES NOT APPEAR WARRANTED.


3. IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A
DIFFERENT MENTAL DISORDER(S), please review the service treatment records
(STRs) and service personnel records for in-service direct evidence. Direct
evidence is clear, undisputable proof of an event, injury, or disease. Such
evidence includes, but is not limited to, mental health treatment, mental
health symptoms, or a mental health diagnosis. If direct evidence exists in
the STRs or service personnel records, please provide an opinion as to
whether the mental disorder(s) diagnosed on examination is at least as likely
as not (50 percent or greater probability) caused by or a result of the
direct evidence noted in service. Please provide a rationale for the opinion
and list the evidence used to arrive at your decision. (38 CFR 3.303).


NO DIRECT EVIDENCE LOCATED. OPINION DOES NOT APPEAR WARRANTED

Share this post


Link to post
Share on other sites

Recommended Posts

  • 0
12 minutes ago, ArmyMajor said:

I have been seen at VA mh since April 2018, which was a few days after the C & P....i had been seen by a private therapist and provided their notes as part of the filing of the claim.  I also included.buddy statements.  Will the rater consider the information that is after the C & P exam? The claim went back to gathering info in November (request for VA medical records).

Buddy statements are competent lay evidence. Yes, they must be considered. 

§3.159   Department of Veterans Affairs assistance in developing claims.

(2) Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.

The claim possibly went back because that incompetent examiner failed to provide a rationale. You might see an addendum to the exam in a few days or weeks.

  • Like 1

Share this post


Link to post
Share on other sites

Ad

  • 0

Tbh you have to have markers. No way around not having them. You need some sort of proof. You cant just claim a foot injury and then say of course I have one, you know we are and were discourged from reporting it! But I want to get paid now for it! The VA is not going to grant you sc unless there is a connection, even if you have private therapists or doctor notes. Its not fair to expect them to do so. Pull your c file and look for markers. 

Over the last few months I have worked with a lot of vets advocating with my local vso and vet center. If you experienced trama that warrants a rating,  you will have a marker somewhere in your file. I have now have helped with 30+ claims for mst.  I am by no means a expert but its a denial and no amount of suger coating will change that. Of course you can add an expert opinion but that will not add markers that you need and they look for. Buddy statements will not add markers. 

 

Sorry. I would be happy to go over your c file with you and see if there are any they have missed. Pm me if you want.

Share this post


Link to post
Share on other sites
  • 0

I found this link on the VA's MST page: https://www.benefits.va.gov/BENEFITS/factsheets/serviceconnected/MST.pdf

It shows some examples of markers they use to help verify claims. My apologies about the text formatting below, but I tried to clean it up as best as possible.

I hope this helps.

Quote

Disability Claim Evidence
The following can support your MST claim:
• Department of Defense sexual assault or harassment reporting forms
• Investigative reports completed during military service

We know not all sexual trauma events are reported. PTSD claims related to MST require less evidence. Instead, we now look for “markers.” These may be signs, events or circumstances. These provide some clue the traumatic event happened. Some examples of markers are:
• Records from official sources
  o Law enforcement
  o Rape crisis centers 3
  o Mental health counseling centers
  o Hospitals o Physicians
• Pregnancy tests
• Tests for sexually transmitted diseases
• Statements from others
  o Family members
  o Roommates
  o Clergy members
  o Fellow Service members
  o Counselors
• Requests for transfer to another military duty assignment
• Decrease in work performance
• Substance abuse
• Episodes of the following without clear cause:
  o Depression
  o Panic attacks
  o Anxiety
• Unexplained behavior (economic or social)
• Relationship issues, like divorce
• Sexual dysfunction


Standards of Evidence for MST-Related PTSD

Claims In 2002 (this is a typo, it was 2012), we relaxed required evidence standards for these claims. We did this to consider all available evidence. Military service records may not contain the evidence you need. VA regulation now states that evidence from non-military sources can be used.

Sometimes direct evidence of an MST is not available. In these cases, we may request a medical opinion. We will also use any markers to verify the MST. This will help relate it to current PTSD symptoms.

 

Share this post


Link to post
Share on other sites
  • 0
23 hours ago, broncovet said:

Yes, there is a way to overcome this unfavorable exam.  You need an IMO/IME.  Or, possibly another VA doc who can render a more favorable opinion.  One bad exam does not necessarily mean the Vet wont get benefits, he just needs to persist and overcome this negative exam with favorable medical evidence.  

Broncovet, since the C & P, I have had two or three differing opinions that contradicts the C & P clinical psychologist evaluation (one psychiatrist/md, clinical pharmacist and another clinical psychologist that I saw within a week of the C & P.).  I know that we all are hoping for the best.  Her review was why so many people are hesitant in coming forward.  Thank you for the feedback.

Share this post


Link to post
Share on other sites
  • 0
3 hours ago, Vync said:

I found this link on the VA's MST page: https://www.benefits.va.gov/BENEFITS/factsheets/serviceconnected/MST.pdf

It shows some examples of markers they use to help verify claims. My apologies about the text formatting below, but I tried to clean it up as best as possitble.

I hope this helps.

 

Vync, thank you for the information, there are markers that are contained in my record.  I requested an immediate transfer from the unit and another marker is that I requested to retire, ilo of staying in the military.  Of course, I had buddy statements to validate the change in my well-being and overall change in myself.  I thank you in advance and your post has been extremely helpful.  I hope that they look at the overwhelming evidence that has been provided through several therapy sessions and not just with short visit with the C & P examiner.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Our picks

    • CBO Options for Reducing the Deficit: 2019 to 2028 Published Dec 2018
      CBO Options for Reducing the Deficit: 2019 to 2028 - This CBO Report has been making the news. This post includes parts relevant to veterans. Nothing has been decided as of yet and some seem very unlikely but you never know. Forewarned is Forearmed.

       

      https://www.hadit.com/cbo-options-for-reducing-the-deficit-2019-to-2028-published-dec-2018/
      • 6 replies
    • 2019 Veterans Benefits
      State Benefits, Space A and More ... https://www.hadit.com/2019-changes-to-veterans-benefits-state-and-federal/
      • 2 replies
    • Appeal granted and closed.
      My appeal was granted and closed on November 9.  I got an unofficial notification from the DAV on November 15 stating "appeal granted with an evaluation of 30%" which is great!  My question is this:  How long until I get the official notification from the va? Nothing on ebennies has updated since the appeal closed. Appeal is now in historical and just says complete and at originating va office. I understand no one knows va timelines to a tee but a general timeline would be great.  Thank you all! Hope you have a Merry Christmas!

       

      Edit:  This was my first time appealing and it was a VBA grant. 
      • 6 replies
    • Question About Temporary 100% Rating for Hospitalization
      Hey all. I've searched all over the net, and read the CFR on the topic. I will be going to PTSD Dom inpatient treatment here soon. I read that it's possible to get 100% temp for hospitalization. However, the CFR says that PTSD Dom does not qualify, but then in the exceptions it says that it may. Does anyone know if I will qualify for temp 100%. I will be in there for almost 2 months. Here is the CFR code, and the part regarding the matter-

       

      Do not apply the provisions of 38 CFR 4.29 when a Veteran

      is treated as a resident in a State Veterans’ home is currently receiving a total rating for the disability for which hospitalization was required is a resident in a VA domiciliary program, or is a participant in a live-in/work out program being utilized to facilitate transition to community living.

       

      Exceptions:
      Hospitalization in excess of 21 days for an SC disability in a medical facility located at a State Veterans’ home may entitle the Veteran to hospitalization benefits. Veterans are entitled to hospitalization benefits for treatment in excess of 21 days in a day hospital program if the treatment given is consistent with hospital care for a SC disability even though they are concurrently required to be housed in a VA domiciliary.

      The exceptions part is confusing me. Does anyone know if I am entitled to a temporary 100% rating? I'm currently rated for the same reason I'm going inpatient.
      • 2 replies
    • Abbreviations, Acronyms, etc.
      Abbreviations, Acronyms, etc.
      • 0 replies
  • Ads

  • Popular Contributors

  • Ad

  • Latest News
  • Our picks

    • CBO Options for Reducing the Deficit: 2019 to 2028 Published Dec 2018
      CBO Options for Reducing the Deficit: 2019 to 2028 - This CBO Report has been making the news. This post includes parts relevant to veterans. Nothing has been decided as of yet and some seem very unlikely but you never know. Forewarned is Forearmed.

       

      https://www.hadit.com/cbo-options-for-reducing-the-deficit-2019-to-2028-published-dec-2018/
      • 6 replies
    • 2019 Veterans Benefits
      State Benefits, Space A and More ... https://www.hadit.com/2019-changes-to-veterans-benefits-state-and-federal/
      • 2 replies
    • Appeal granted and closed.
      My appeal was granted and closed on November 9.  I got an unofficial notification from the DAV on November 15 stating "appeal granted with an evaluation of 30%" which is great!  My question is this:  How long until I get the official notification from the va? Nothing on ebennies has updated since the appeal closed. Appeal is now in historical and just says complete and at originating va office. I understand no one knows va timelines to a tee but a general timeline would be great.  Thank you all! Hope you have a Merry Christmas!

       

      Edit:  This was my first time appealing and it was a VBA grant. 
      • 6 replies
    • Question About Temporary 100% Rating for Hospitalization
      Hey all. I've searched all over the net, and read the CFR on the topic. I will be going to PTSD Dom inpatient treatment here soon. I read that it's possible to get 100% temp for hospitalization. However, the CFR says that PTSD Dom does not qualify, but then in the exceptions it says that it may. Does anyone know if I will qualify for temp 100%. I will be in there for almost 2 months. Here is the CFR code, and the part regarding the matter-

       

      Do not apply the provisions of 38 CFR 4.29 when a Veteran

      is treated as a resident in a State Veterans’ home is currently receiving a total rating for the disability for which hospitalization was required is a resident in a VA domiciliary program, or is a participant in a live-in/work out program being utilized to facilitate transition to community living.

       

      Exceptions:
      Hospitalization in excess of 21 days for an SC disability in a medical facility located at a State Veterans’ home may entitle the Veteran to hospitalization benefits. Veterans are entitled to hospitalization benefits for treatment in excess of 21 days in a day hospital program if the treatment given is consistent with hospital care for a SC disability even though they are concurrently required to be housed in a VA domiciliary.

      The exceptions part is confusing me. Does anyone know if I am entitled to a temporary 100% rating? I'm currently rated for the same reason I'm going inpatient.
      • 2 replies
    • Abbreviations, Acronyms, etc.
      Abbreviations, Acronyms, etc.
      • 0 replies
×

Important Information

{terms] and Guidelines