C&P to Separate Anxiety Disorder from TBI

[damnitface77 0]

For Starters, I want to thank anyone who takes the time to read this and give me a little perspective. I just got my final C&P results after a series of claims. Currently I am 94% combined rating if I include my Sleep apnea claim (The Dr. wrote it was medically neccesary to use the CPAP, so I do expect the 50%. This C&P below was conducted to separate my anxiety disorder from my TBI disorder. Currently I have a 70% rating for Anxiety with residuals of TBI. I was wondering if anyone could read this and tell me if they think I can expect a separate rating for TBI memory loss based on the Dr's opinion stating that my issue is 80% anxiety and 20% TBI (see note 2b below). If I can get at least a 10% for TBI in addition to the 70% for anxiety, It should push me over the threshhold of 100% schedular. The only edits I made to this was to remove names.  Again, thank you for your time and expertise

70% Anxiety (Trauma with TBI residuals)

50% Sleep Apnea

20% Degenerative Disc Disease

20% Upper Neuropathy Right / 20% Upper Neuropathy Left

10% Lower Radiculopathy Right / 10% Lower Radiculopathy Left

0% TBI Migraines

LOCAL TITLE: COMP AND PEN NOTE
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JAN 28, 2019@14:30 ENTRY DATE: JAN 30, 2019@11:11:26

AUTHOR: *********** E EXP COSIGNER: URGENCY: STATUS: COMPLETED

Mental Disorders
(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire Name of patient/Veteran: *****

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination

Request?
[X] Yes [ ] No

SECTION I: ----------

1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)? [X] Yes [ ] No

ICD code: 300.00

If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Unspecifed Anxiety disorder, chronic, severe

disorder.
ICD code: 300.00 Comments, if any:

Vet had been seen initially on 2/11/18 for Mental Health C+P exam done

by Dr. *****(which proposed "Anxiety disorder, NOS" then, while f/u

C+P exam on 2/16/14 had proposed Other specified trauma and stressor related disorder(as vet had been in IED blast in 2006 - see Mental Disorder diagnosis #2 below.

Unspecified anxiety disorder is synonymous with Neurosis - which vet is

already 70% SC for, in combination with residuals of TBI apparently). I

am therefore not intending to change his Neurosis condition now, but Unspecified anxiety disorder is most accurate diagnosis consistent with DSM-V, as I see it now.

Mental Disorder Diagnosis #2: Cognitive disorder due to Closed Head

iInjury(CHI), due to 6/1/2006 "double-attacked anti-tank mine" IED blast.

ICD code: 294.9 Comments, if any:

Vet was in 2nd Iraq combat deployment - out of 3 tours he served there -

when 6/1/06 IED hit his heavy equipment vehicle(which vet had referred to as 'palitizing loading system').

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Vet is already 0% SC for

migraine headaches.

Comments, if any:
Vet is already SC for migraine headaches. Vet is already 20% SC for Intervertebral DIsc Syndrome, 20% SC for Paralysis of musculospiral nerve(x2), 10% SC fo paralysis of sciatic nerve(x2).

Vet also apparently had a 2/15/18 sleep study done that indicated a mild

sleep apnea condition.

2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?

[X] Yes [ ] No

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes [ ] No [ ] Not applicable (N/A)

If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses

Symptoms(i.e., anxiety, sleep problmes) are due to Unspecified

anxiety disorder, while symptoms(memory problems, headaches) are due

to Cognitive disorder due to CHI.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to TBI

and any non-TBI mental health diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A)

If yes, list which symptoms are attributable to TBI and which symptoms

are attributable to a non-TBI mental health diagnosis see 2b above.

3. 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 with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or

mood

b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A)

If yes, list which occupational and social impairment is attributable to each diagnosis

About 80% of vet's current occupational and social impairment is due

to Unspecified anxiety disorder while about 20% is due to Cognitive disorder due to CHI.

c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [X] Yes [ ] No [ ] Not Applicable (N/A)

If yes, list which impairment is attributable to TBI and which is attributable to any non-TBI mental health diagnosis see 3b above.

SECTION II:

----------- Clinical Findings: ------------------

1. Evidence Review
------------------
Evidence reviewed (check all that apply):

[X] VA e-folder
[X] CPRS
[X] Other (please identify other evidence reviewed):

Vet broiught a 4 page typed letter 1/12/19 done by himself describing

in detail his current ongoing issues("I did not want to forget to tell

you something important"), and vet admits it took him severalhours to

complete(and which he kept revising many times). He brought a 2 page

letter dated 1/27/19 done by his wife ******, a 2 page typed letter dated

1/17/19 done by mother ********, and a 1 page typed letter dated

1/27/19 done by vet's friend/combat comrade(served together in Iraq)

named *******, and all 4 letter were reviewed by me.

Evidence Comments:
CPRS was reviewed by me and included my(***** MD) 12/5 18 Review TBI C+P exam report, as well as 5/16/14 C+P exam report done by Dr *****(sa

well
as Initial 2/18/11 MH C+P exam aslo done by Dr. ******.

VBMS was reviewed by me and included vet's Army DD-214 signed b *****

which included MOS(88M30) Mortor Vehicle Operator,as well as E-6 discharge

rank. His medals included CAB - among others, and he had Iraq combat dates

of 1/03 - 7/03, 8/05 - 8/06, and 3/08 - 6/09 - for his 3 seperate Iraq combat tours.

2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):
Vet is married ****(and they have 2 sons(around ages 5 and nearly 7).

b. Relevant Occupational and Educational history (pre-military, military, and

post-military): Vet has been working in his current Passport Agency job since 2015(was at an administrative clerk(for a different agency) before that.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military,

and post-military):

Vet has been on sertraline 150mg since 9/10/18 - it takes the "edge" off

my problems, but he apparently has been having some sexual side effects(delayed ejaculation) related to that .

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

Vet has had no legal problems(and no jail time) since the 5/14/16 C+P exam report date.

e. Relevant Substance abuse history (pre-military, military, and post-military):

Vet has had no alcohol misuse disorder problems sicne 5/16/14. He has used no street drugs since 16/14.

f. Other, if any:
No response provided.

3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent

events
[X] Impairment of short- and long-term memory, for example, retention of

only highly learned material, while forgetting to complete tasks
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social

relationships
[X] Difficulty in adapting to stressful circumstances, including work or

a
worklike setting

[X] Obsessional rituals which interfere with routine activities

4. Behavioral observations
--------------------------
Vet was totally genuine at the 1/28/19 Review Mental Health C+P exam.

5. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes [ ] No If yes, describe: Vet admits to having anger difficulties, 'spacing out' at times, and general feeling of being confused/overwhelmed. He reports having lost his social "filter" abilities. He reports previously having been very "easygoing" prior to the military. Vet still gets nervous if seeing sandbags lying on the side of the road - left by construction crew(as that is what he looked for over in Iraq as being a potential IED.) He has to reorganize plates/trays a certain way, either at home or when leaving a restaurant, respectively. He denies having any suicidal thoughts("No, I'm addicted to life, I love breathing".). 6. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: --------------------------------------------------- Vet owns a pistol. He does not hunt - only tried it once, but did not get anything then. He denied having any current active suicidal or homicidal ideation.

[broncovet 3,293]

I dont see this exam warranting an increase.  All mh disorders are rated on the same criteria, and you can only get paid for One set of symptoms even if you have 8 different mental health disorder diagnosis.  To get an increase from 70 percent, you would have needed the doc check "Total occupational and social impairment", which is the criteria for 100 percent. 

Instead, your doctor indicated the criteria for 70 percent for MH disorders.  Your doctor indicated you are working (employed).  If this is accurate, its gonna be difficult for you to get a 100 percent rating for mental disorders.  

[doc25 59]

11 hours ago, damnitface77 said:

For Starters, I want to thank anyone who takes the time to read this and give me a little perspective. I just got my final C&P results after a series of claims. Currently I am 94% combined rating if I include my Sleep apnea claim (The Dr. wrote it was medically neccesary to use the CPAP, so I do expect the 50%. This C&P below was conducted to separate my anxiety disorder from my TBI disorder. Currently I have a 70% rating for Anxiety with residuals of TBI. I was wondering if anyone could read this and tell me if they think I can expect a separate rating for TBI memory loss based on the Dr's opinion stating that my issue is 80% anxiety and 20% TBI (see note 2b below). If I can get at least a 10% for TBI in addition to the 70% for anxiety, It should push me over the threshhold of 100% schedular. The only edits I made to this was to remove names.  Again, thank you for your time and expertise

70% Anxiety (Trauma with TBI residuals)

50% Sleep Apnea

20% Degenerative Disc Disease

20% Upper Neuropathy Right / 20% Upper Neuropathy Left

10% Lower Radiculopathy Right / 10% Lower Radiculopathy Left

0% TBI Migraines

LOCAL TITLE: COMP AND PEN NOTE
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JAN 28, 2019@14:30 ENTRY DATE: JAN 30, 2019@11:11:26

AUTHOR: *********** E EXP COSIGNER: URGENCY: STATUS: COMPLETED

Mental Disorders
(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire Name of patient/Veteran: *****

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination

Request?
[X] Yes [ ] No

SECTION I: ----------

1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)? [X] Yes [ ] No

ICD code: 300.00

If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Unspecifed Anxiety disorder, chronic, severe

disorder.
ICD code: 300.00 Comments, if any:

Vet had been seen initially on 2/11/18 for Mental Health C+P exam done

by Dr. *****(which proposed "Anxiety disorder, NOS" then, while f/u

C+P exam on 2/16/14 had proposed Other specified trauma and stressor related disorder(as vet had been in IED blast in 2006 - see Mental Disorder diagnosis #2 below.

Unspecified anxiety disorder is synonymous with Neurosis - which vet is

already 70% SC for, in combination with residuals of TBI apparently). I

am therefore not intending to change his Neurosis condition now, but Unspecified anxiety disorder is most accurate diagnosis consistent with DSM-V, as I see it now.

Mental Disorder Diagnosis #2: Cognitive disorder due to Closed Head

iInjury(CHI), due to 6/1/2006 "double-attacked anti-tank mine" IED blast.

ICD code: 294.9 Comments, if any:

Vet was in 2nd Iraq combat deployment - out of 3 tours he served there -

when 6/1/06 IED hit his heavy equipment vehicle(which vet had referred to as 'palitizing loading system').

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Vet is already 0% SC for

migraine headaches.

Comments, if any:
Vet is already SC for migraine headaches. Vet is already 20% SC for Intervertebral DIsc Syndrome, 20% SC for Paralysis of musculospiral nerve(x2), 10% SC fo paralysis of sciatic nerve(x2).

Vet also apparently had a 2/15/18 sleep study done that indicated a mild

sleep apnea condition.

2. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?

[X] Yes [ ] No

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes [ ] No [ ] Not applicable (N/A)

If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses

Symptoms(i.e., anxiety, sleep problmes) are due to Unspecified

anxiety disorder, while symptoms(memory problems, headaches) are due

to Cognitive disorder due to CHI.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to TBI

and any non-TBI mental health diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A)

If yes, list which symptoms are attributable to TBI and which symptoms

are attributable to a non-TBI mental health diagnosis see 2b above.

3. 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 with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or

mood

b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A)

If yes, list which occupational and social impairment is attributable to each diagnosis

About 80% of vet's current occupational and social impairment is due

to Unspecified anxiety disorder while about 20% is due to Cognitive disorder due to CHI.

c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [X] Yes [ ] No [ ] Not Applicable (N/A)

If yes, list which impairment is attributable to TBI and which is attributable to any non-TBI mental health diagnosis see 3b above.

SECTION II:

----------- Clinical Findings: ------------------

1. Evidence Review
------------------
Evidence reviewed (check all that apply):

[X] VA e-folder
[X] CPRS
[X] Other (please identify other evidence reviewed):

Vet broiught a 4 page typed letter 1/12/19 done by himself describing

in detail his current ongoing issues("I did not want to forget to tell

you something important"), and vet admits it took him severalhours to

complete(and which he kept revising many times). He brought a 2 page

letter dated 1/27/19 done by his wife ******, a 2 page typed letter dated

1/17/19 done by mother ********, and a 1 page typed letter dated

1/27/19 done by vet's friend/combat comrade(served together in Iraq)

named *******, and all 4 letter were reviewed by me.

Evidence Comments:
CPRS was reviewed by me and included my(***** MD) 12/5 18 Review TBI C+P exam report, as well as 5/16/14 C+P exam report done by Dr *****(sa

well
as Initial 2/18/11 MH C+P exam aslo done by Dr. ******.

VBMS was reviewed by me and included vet's Army DD-214 signed b *****

which included MOS(88M30) Mortor Vehicle Operator,as well as E-6 discharge

rank. His medals included CAB - among others, and he had Iraq combat dates

of 1/03 - 7/03, 8/05 - 8/06, and 3/08 - 6/09 - for his 3 seperate Iraq combat tours.

2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):
Vet is married ****(and they have 2 sons(around ages 5 and nearly 7).

b. Relevant Occupational and Educational history (pre-military, military, and

post-military): Vet has been working in his current Passport Agency job since 2015(was at an administrative clerk(for a different agency) before that.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military,

and post-military):

Vet has been on sertraline 150mg since 9/10/18 - it takes the "edge" off

my problems, but he apparently has been having some sexual side effects(delayed ejaculation) related to that .

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

Vet has had no legal problems(and no jail time) since the 5/14/16 C+P exam report date.

e. Relevant Substance abuse history (pre-military, military, and post-military):

Vet has had no alcohol misuse disorder problems sicne 5/16/14. He has used no street drugs since 16/14.

f. Other, if any:
No response provided.

3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent

events
[X] Impairment of short- and long-term memory, for example, retention of

only highly learned material, while forgetting to complete tasks
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social

relationships
[X] Difficulty in adapting to stressful circumstances, including work or

a
worklike setting

[X] Obsessional rituals which interfere with routine activities

4. Behavioral observations
--------------------------
Vet was totally genuine at the 1/28/19 Review Mental Health C+P exam.

5. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [X] Yes [ ] No If yes, describe: Vet admits to having anger difficulties, 'spacing out' at times, and general feeling of being confused/overwhelmed. He reports having lost his social "filter" abilities. He reports previously having been very "easygoing" prior to the military. Vet still gets nervous if seeing sandbags lying on the side of the road - left by construction crew(as that is what he looked for over in Iraq as being a potential IED.) He has to reorganize plates/trays a certain way, either at home or when leaving a restaurant, respectively. He denies having any suicidal thoughts("No, I'm addicted to life, I love breathing".). 6. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: --------------------------------------------------- Vet owns a pistol. He does not hunt - only tried it once, but did not get anything then. He denied having any current active suicidal or homicidal ideation.

I don't think TBI and the anxiety can be seperated. 

You could request a 10% increase for your Migraines. And that will put you at 95%. 

Migraine Headaches

Code 8100: Migraine headaches are a type of headache caused by the swelling of the blood vessels in the brain. They are often more severe than other kinds of headaches (stress, sinus, etc.), and so interfere more with the individual’s ability to work and function in daily life. If another kind of headache interferes significantly with daily life, it can also be rated here.

Two things are taken into account when rating migraines: frequency (how often they occur) and severity (how bad they are). To receive a proper rating, it is essential that the physician records these clearly along with how they affect the individual’s ability to work and function.

The term “prostrating” means that the individual must stop all activity, take medication, and either seek medical attention or seclude himself for the rest of the day. The individual is unable to perform any occupational or daily activities either because of the migraine itself or because the migraine medication makes him too drowsy, etc.

The ratings for migraines only go up to 50%. The Rating Authorities, however, can give a higher rating if the case is so severe that 50% doesn’t truly reflect the disability. It is completely up to the Rating Authorities, however, exactly what makes a condition severe enough to warrant a higher rating.

Frequency	Severity	Rating
2 or more times per month	Prostrating	50%
Once a month	Prostrating	30%
Once every 2 months and prostrating		10%
Once every 3 months or less	Prostrating	0%

OR....

Apply for Individual Unemployability if you feel that Anxiety has kept you from working.

 

[Berta 3,237]

If you were unemployed at time of the 70% rating, the VA would have considered you for TDIU.

If the anxiety gets worse to the point you can no longer wotrk- by all means apply for TDIU and also for SSDI.

TBI and anxiety disorders to include PTSD can be separated:

 

"After review of the evidence, the Board resolves all reasonable doubt in favor of the Veteran to find that separate ratings for TBI and PTSD are warranted. While the June 2012 examiner was unable to distinguish symptoms, other examiners have provided evidence of the separate symptomatology for the TBI and PTSD conditions. By way of this decision, a separate 40 percent rating for TBI is assigned effective January 19, 2012. After review of the evidence, the Board resolves all reasonable doubt in favor of the Veteran to find that separate ratings for TBI and PTSD are warranted. While the June 2012 examiner was unable to distinguish symptoms, other examiners have provided evidence of the separate symptomatology for the TBI and PTSD conditions. By way of this decision, a separate 40 percent rating for TBI is assigned effective January 19, 2012."

https://www.va.gov/vetapp18/files11/18152985.txt

The regulations changed on TBI and MH disorders, some years back and the newer regulations are here under a search.

[Berta 3,237]

This holds the new TL on TBI and DC 8045 but I dont have permissions to open it-

It might not apply to this vet but maybe to others-

 

[vetquest 239]

The new regulations might be in but it does not mean the RO will apply them.  Check your decision carefully and see if the TBI and PTSD are rated separately or if they are lumped in as a psychological disorder.  If not then you can appeal.  The previous BVA decision can be referenced in your appeal but is not precedent.  Note that TBI is defined under diagnostic code 8411-8100 and PTSD is defined under DC 9411.  Therefore TBI is a separate and distinct disability.  The RO's make mistakes in decisions but the BVA is more careful to apply the regulations as required.