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Sinus Condition denied due to pre-service surgery?


Retired USAF 1st Sergeant

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First post/question . Advance thanks to ALL my fellow Veterans.

I retired November 2004 with 21+ years service (USAF). I'm now 56.

I filed my initial VA claim in Oct 2005 with no VSO or any other guidance whatsoever.

Received an initial SC rating of 70%, - 50% OSA, 20% BPH, 10% L Knee, 10% R knee. I was Fat, Dumb and Happy...😎

I was denied SC for Sinus condition due to a pre-service surgery for deviated septum/removal of polyps.This surgery was ~3 years prior to enlistment (~1980) and was disclosed during MEPS/Inprocessing. I started having sinus issues (multiple recurrent infections) and subsequently two sinus surgeries (~1995 & ~2000). I still have recurrent yearly sinus infections that require treatment with antibiotics and steroids. 

Fast forward to January, 2019. All of my SC issues have  gotten worse over the years. 

I signed up with a VSO who was highly recommended by a Veteran friend. He reviewed my In-service Medical Records. While reviewing my records. he noted that the sinus issues were "all over my records and asked why hadn't I claimed them?" I told him that I had claimed the sinus condition in my initial claim back in 2005, and it was denied. He then pulled up and read my initial rating decision letter and said, "They screwed you on this. We need to file a reopen". The VSO filed a new claim for this and other conditions 01/09/2019. I"m expecting another denial. Do I have a legitimate basis to disagree or appeal?

Edited by Retired USAF 1st Sergeant
spelling correction (see edit history)
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Of course, I have not read your records.  However, it sounds like this qualifies under Caluza element number 2, "In service event OR AGGRAVATION".  

Remember, tho, VA math is not in your favor MATH.  An additional 10 percent or maybe even an additional 20 percent "does not always" result in an increase because of VA math.  

You could use the disability calculator, and check the critieria and see, but, why fight the VA for nothing??  That is, if its unlikely to mean more money in your pocket, I would not bother. Some may disagree, but you are unlikely to die from a sinus condition...

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Thanks for the guidance Broncovet. I really appreciate it.

An additional 20% (of the remaining 30) would get me to 80% SC. And I've requested increases for BPH and both knees.

I'm really looking for an answer to the question,  Was it correct/legitimate for the VA to deny the original claim due to the pre-service surgery?  

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No, its not correct.  They have to rate "aggravation" to the extent your condition got worse in service.  You dont get paid for the part you had before service.  What I dont know if the worsening of symptoms is significant or not.  You know that better than I do.  

Edited by broncovet (see edit history)
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Here is what I found out. The US government bought you the way you were and your condition got worse, so from what I understand they own this part of you also. 

I had a condition prior to service and it was aggravated by other conditions or was made worse in service so they own all of it. 

The prior part you will get nothing. 

Also I don’t think it is a waste as your other conditions could go higher also. 

Edited by shrekthetank1 (see edit history)
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Thanks shrek, that helps. 

I may be wrong, but the reason I think they're going to deny again is because I haven't been scheduled for a C&P exam for the sinus condition. 

I already had the C&P exams for the requested increases on BPH and both knees, and have another C&P scheduled next Tuesday for Hearing/Tinnitus

Also completed one for lab work (blood & urine)

I guess I'll just have to wait and see... 

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4 hours ago, Retired USAF 1st Sergeant said:

First post/question . Advance thanks to ALL my fellow Veterans.

I retired November 2004 with 21+ years service (USAF). I'm now 56.

I filed my initial VA claim in Oct 2005 with no VSO or any other guidance whatsoever.

Received an initial SC rating of 70%, - 50% OSA, 20% BPH, 10% L Knee, 10% R knee. I was Fat, Dumb and Happy...😎

I was denied SC for Sinus condition due to a pre-service surgery for deviated septum/removal of polyps.This surgery was ~3 years prior to enlistment (~1980) and was disclosed during MEPS/Inprocessing. I started having sinus issues (multiple recurrent infections) and subsequently two sinus surgeries (~1995 & ~2000). I still have recurrent yearly sinus infections that require treatment with antibiotics and steroids. 

Fast forward to January, 2019. All of my SC issues have  gotten worse over the years. 

I signed up with a VSO who was highly recommended by a Veteran friend. He reviewed my In-service Medical Records. While reviewing my records. he noted that the sinus issues were "all over my records and asked why hadn't I claimed them?" I told him that I had claimed the sinus condition in my initial claim back in 2005, and it was denied. He then pulled up and read my initial rating decision letter and said, "They screwed you on this. We need to file a reopen". The VSO filed a new claim for this and other conditions 01/09/2019. I"m expecting another denial. Do I have a legitimate basis to disagree or appeal?

Read this BVA citation. It will provide you some insight on what you'll need to do. This service member's pre-existing condition worsened during service and service connection was granted on the basis of aggravation.

 

https://www.va.gov/vetapp08/files2/0814999.txt

 

 

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Thanks doc25.

Your attachment almost exactly describes my situation, except that my sinus infections were so severe and recurring that I had to have surgery twice during service. I still have recurrent sinus infections usually 1-2 times a year that require steroids and 1-2 rounds of antibiotics to clear up. I have one now, going on since mid January.

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34 minutes ago, Retired USAF 1st Sergeant said:

Thanks doc25.

Your attachment almost exactly describes my situation, except that my sinus infections were so severe and recurring that I had to have surgery twice during service. I still have recurrent sinus infections usually 1-2 times a year that require steroids and 1-2 rounds of antibiotics to clear up. I have one now, going on since mid January.

Disclosure: (I'm not an actual doctor, but I have medical experience as a Navy Corpsman.)

I suspect your condition sounds like Sinusitis. Please correct me if I'm wrong. Here is how Sinusitis is rated to give you an idea of what it would be rated, if it is granted.

Sinusitis Rating System

Sinusitis occurs when the sinuses swell and is most often caused by infection or allergy. Most sinusitis is easily cleared up within 2 weeks, and so it is only ratable if it is chronicchronic.bmp. Sinusitis can occur in each of the different sinuses or in all at the same time (“pansinusitis”). Treatments range from medication to surgery.

If the sinusitis is constant or near-constant with headaches, tenderness to the touch, and the discharge of puss or crusting after repeated surgeries, or if a radical surgeryradical.bmp was performed and there is ongoing infection in the facial bones (osteomyelitis), it is rated 50%.

If there are 3 or more incapacitating episodesincapacitating.bmp each year that requires 4 to 6 weeks of antibiotic treatment, or if there are more than 6 episodes (not incapacitating) each year of headaches, tenderness and the discharge of puss or crusting, it is rated 30%.

If there are 1 or 2 incapacitating episodes each year that requires 4 to 6 weeks of antibiotic treatment, or if there are 3 to 6 episodes each year of headaches, tenderness, and the discharge of puss or crusting, it is rated 10%.

Anything less is rated 0%.

Sinusitis codes:

– Code 6510: Pansinusitis
– Code 6511: Ethmoid sinusitis
– Code 6512: Frontal sinusitis
– Code 6513: Maxillary sinusitis
– Code 6514: Sphenoid sinusitis

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14 hours ago, doc25 said:

Read this BVA citation. It will provide you some insight on what you'll need to do. This service member's pre-existing condition worsened during service and service connection was granted on the basis of aggravation.

https://www.va.gov/vetapp08/files2/0814999.txt

That is a good BVA case.

When filing for aggravation, one thing to keep in mind is the rating % difference between what was found during the entrance exam vs. later/now. The VA should use the rating criteria to match against your records. 

Formula: % now - % at entrance exam = % aggravation

I am SC for allergic rhinitis due to aggravation. The VA claimed the aggravation was at the 10% level, so they deducted 10% from my 30% rating, leaving me with a 20% rating. It was years later that I learned that the rating staff cannot interject their opinion and must rely solidly on the rating criteria. I am contemplating a CUE because my entrance exam merely has a checkbox by sinus issues and there is no indication it met the 10% rating criteria in effect at the time the rating was granted.

 

 

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