Claim Denied. Please help. Confused

[USMC_SawGunner]

Apologize for the length(a lot you can just skim over) but I want to put this all out there because I am stunned right now. After 60 days, my claim was abruptly denied. No C&P exam requested. Please tell me how anyone can possibly defend what you are about to read. I have carefully redacted all personal information about myself or my doctors.

________________________________________________________________________________________

 

Below, I have just copy and pasted these sample entries from my bluebutton report. There are many more examples over the course of seeing my VA doctors for over a year but I just grabbed a few entries to give you a clear idea of what they have been writing down in my file. These are just some of the recent entries as you can see by the date. I also have a medication list that is over 2 pages long of drugs I have tried since getting help from them. I am still continuing to see my doctors and receiving treatment.

_______________________________________________________________________________________

 

Mar 15(VA Psychologist): Diagnosis: Major Depression

Quote

"Client states his level of back pain has become significant enough where he withdrew from job."

_______________________________________

March 15(VA Psychiatrist): Dx: Major depressive disorder, recurrent, severe; Insomnia disorder with non sleep mental comorbidity; adjustment disorder with anxiety

Quote

"mood and physiological pain continues to cause significant impairment in employment, and social/interpersonal functioning. He continues to report minimal improvement in mood or chronic pain with his current medication regimen. chronic low back pain from service"

_______________________________________

 

March1(VA Psychiatrist): Dx: Major depressive disorder, recurrent, severe; Insomnia disorder with non sleep mental comorbidity; adjustment disorder with anxiety.

Quote

"Veteran's mood continues to cause significant impairment in employment, emotional, and social/interpersonal functioning. He continues to report minimal to no improvement with medications for mood, anxiety, or pain."

"client reports engaging in pain management for lower back pain. Client reports some significant discomfort and chronic pain. Talked about the effect of chronic pain and how it can exacerbate his level of depression."

 

_______________________________________

 

Jan 04 (pain management doctor): Chief complaint: low back pain

Quote

"Mr XXX male with PMH significant for depression that presents today for f/u for low back pain. He reports no improvement of low back pain. Also reports lower extremity weakness with legs giving out after back tensing up."

 

 

_____________________________________

 

 

Sep 13 Last year(Older VA Psych who retired): DX: depression, chronic low back pain.

Quote

"Vet continues to struggle with back pain. He expects that he may never work again, have no quality of life."

 

 

___________________________________

 

October 22 Last year(Older VA Psych who retired): DX: Unspecified depressive disorder; unspecified anxiety disorder with panic attack, Insomnia, unspecified.

 

Quote

 

"Veteran continues to report experiencing depression, anxiety irritability, panic attack and insomnia secondary to chronic low-back pain that is constantly 8/10" Veterans mood and symptoms continue to cause mild impairment in employment, and significant impairment in social and interpersonal functioning. Has experienced little improvement in symptoms. MEDICAL ROS: Chronic low-back pain from service"

 

_______________________________________

 

In addition to these notes, I went out and got TWO seperate DBQ's filled out by my local doctors. They are both board certified psychologist.

 

Here are the DBQ's with all personal information redacted:

 

 

https://imgur.com/a/ztSD9SS Private board certified doctors DBQ #1 

 

https://imgur.com/a/XDF4kTC Second Private board certified doctors DBQ #2 

 

_________________________________________

 

Lastly, I included in my FDC package 3 buddy statements from family members and co-workers indicating how my lower back has affected my life and job and how it has manifested into depression due to chronic pain.

 

_______________________________________________________

 

Everything you see above, resulted in this:  https://imgur.com/a/9NmbYMd     60 days and not even a C&P exam request.  

 

My mind is BLOWN right now. How.

 

EDIT: I have worked manual labor construction my entire life, due to how bad the back pain has gotten and now the depression I have been out of work for over 6 months. I will now be applying for food stamps. God Bless the VA.

[doc25]

On 6/1/2019 at 3:42 PM, USMC_SawGunner said:

Thanks for taking the time to reply.

 

Regarding the DBQ's.  I am around vets often, participate in group therapy, and get around online a bit to the different forums.  I know of no one I have ever talked to who went out and dropped $400 EACH for two separate independent DBQ's from board certified doctors to submit with their initial claim. No one.   Like you said, if they simply give the rater a better picture of my symptoms, good enough.  I want my symptoms as fleshed out as possible and on the record. I did not expect to get an immediate rating based purely off the DBQ's.

 

I have posted this same question elsewhere with lines such as this from the head Pain Psychologist(MD) specialist at my local VA and somehow they are invalid and do not meet the level of creating a "Nexus" and at MINIMUM trigger a C&P to evaluate "nexus". Below is what she wrote and what is in my file right now:

Dx: Major depressive disorder, recurrent, severe; Insomnia disorder with non sleep mental comorbidity; adjustment disorder with anxiety.  

"Veteran continues to report experiencing depression, anxiety irritability, panic attack and insomnia secondary to chronic low-back pain that is constantly 8/10" Veterans mood and symptoms continue to cause mild impairment in employment, and significant impairment in social and interpersonal functioning. Has experienced little improvement in symptoms. MEDICAL ROS: Chronic low-back pain from service"

So get rid of the DBQ's, Get rid of the lay statements, get rid of ALL the other VA doctor notes and submissions(for the sake of argument and discussion).  Let's just examine this one simple submission in my bluebutton.

What we have is a DX, a medical diagnosis of Severe Major Depressive Disorder, from the VA Pain Psychologist(MD).   That's very clear... I hope.     Now, let's look what they said after they made that diagnosis.  "depression, anxiety irritability, panic attack, and insomnia SECONDARY TO CHRONIC-LOW BACK PAIN."     

 

Explain to me, please, how just that... and that alone is not a form of nexus?  how much more clear could the doctor have put it. She is a MEDICAL DOCTOR, she is not, nor any other medical doctor at the VA, going to utter the phrase "is at least as likely as".   She is clearly indicating the association between her own diagnosis of Major Depression and the origins of it, SECONDARY TO CHRONIC-LOW BACK PAIN...   For which I am 40% service connected. 

 

Remember, we arent talking about ratings right now..  WE ARE TALKING ABOUT NOT EVEN MEETING THE THRESHOLD FOR A C&P.   

 

Thank you for the links to chronic pain and depression but it probably the second most obvious cause of mental health in the world.  It's not even remotely debatable to provide evidence of that.  I don't need to prove or substantiate that.  It's known fact.  

 

Your content will need to be approved by a moderator

 

I don't make up the rules man. This will better explain what I meant.

 

VA Disability - Step 6: When the initial decision finds no "nexus"

What is the "nexus" and why is it important? 

To get benefits, you must meet three tests. You need to show:

• eligibility by your military service,
• diagnosis of a "condition," and
• evidence that the condition started during your military service or, if your condition was preexisting, that it was aggravated by military service.

This third test is the connection or "nexus" between what happened to you in the military and your current medical condition.

Case in point: the back injury story

In many cases this connection, or "nexus" may be tenuous at best. Let's consider, for example, a back injury. You may have hurt your back in some fashion while serving your country. That was in 1970 and you went on sick call. Your sore back was diagnosed as a "pulled muscle" or something similar.  You were given some APC tablets and sent on your way to light duty for 3 days. The back became more painful so you were back on sick call a week later. This time an x-ray was ordered and you were given some stronger pain pills. Your light duty was increased to  restricted duty for a month with orders of no lifting, no PT and so on.

The military culture demands that we don't complain of our "minor" aches and pains. The team depends on each member being ready to complete the mission and the mission is all that counts. From day one we're trained that complaints of pain will bring about scorn from superiors. Fellow soldiers will know that they have to carry your load as well as their own. "Pain", we learn, "is weakness leaving your body." Pain is good. If J.B. Books [John Wayne character in the 1976 movie "The Shootist"] didn't complain about his back pain, why should you?

So you toughed it out, used a lot of aspirin. While your back did improve, you always guarded it and were cautious that you didn't injure yourself again. Your civilian career wasn't as physical as the military. So during the years since your ETS you've had a chronic, low level back pain but it hasn't required much treatment...until now.  In the last year you've had to seek more intensive medical care, and finally you had an MRI. The MRI study shows numerous issues with disks and nerves. You realize that your old service injury is here to haunt you.

You file for service-connected disability compensation. You have a C & P exam. And about a year later you have a denial letter. The VA tells you that although you had complaints during your service, your condition today is new and unrelated to those old problems. Now what?

How do I prove this "nexus"?

The "nexus letter" is the key to winning your appeal. Nexus is defined as "the means of connection between things linked in series."

Your next task is to seek an expert physician who will review your complete medical records. You'll ask him or her to write a letter stating their opinion that your condition today is related to your military service. 

Any physician who is qualified to write a "nexus" letter on your behalf may do so. While it is commonly believed that VA physicians aren't allowed to write such letters, that isn't true. VA physicians, as with many civilian physicians, simply don't like to write such letters. They may not be skilled at this task or may not have the tools at hand to write the letter. And typically they are so busy caring for a heavy load of patients that your issue isn't a priority.

What does the letter look like? 

The nexus letter should follow a similar format to all letters that you use to communicate to VA. It should record only the facts and the doctor's conclusions. It may be addressed directly to you or "To Whom It May Concern." Also, see if the physician is willing to provide you with a current resume to attach to the letter; this will help to support the physician's expertise.  View sample letter.

Note the specific language in the opening and closing paragraphs. Less specific language may not meet the VA standard.  The C & P Service Clinicians Guide  gives the examining physician the exact phrasing to be used in the "nexus" statement. Here is the relevant section of the Guide:

"When asked to give an opinion as to whether a condition is related to a specific incident during military service, the opinion should be expressed as follows:

1. “is due to” (100% sure)
2. “more likely than not” (greater than 50%)
3. “at least as likely as not” (equal to or greater than 50%)
4. “not at least as likely as not” (less than 50%)
5. “is not due to” (0%) "

The importance of using the language  at # 1, 2, or 3 is apparent.

Here is another sample letter.  Again, note the "more likely than not" language in the "nexus" statement. Also, notice that the other medical information is pared down to the essential facts. Here is another note about this letter from it's author,  Jim Strickland: "The only thing missing from this letter is an often-used statement to point out that there are no other known or apparent causes for the current condition. That might read like; "There is no known history of the veterans family having this condition..." or "The veteran has no other known history that would cause or contribute to this condition...". I only include that statement when the cause of the condition is less than apparent. I might use that to show that a cancer was more likely than not caused by exposure to Agent Orange and that the veteran had no family history or exposure to other carcinogenic chemicals that may be seen as a possible cause for the current condition. In this case there were 2 documented traumatic events that were the likely cause of the injury making any reference to other possible causes unnecessary."

How do I get a doctor to support my claim?

It's best to make a routine appointment and meet face-to-face with the doctor. Ask her directly to draft or sign the letter.  Assuming that the physician agrees with your "nexus" claim, it is perfectly acceptable for you to draft the letter on her behalf. Then ask her to review and sign it, or edit and then sign, if she feels more comfortable with that. I advise you not to ask a nurse or clerk to perform the task of getting the physician's signature. These members of the care team often see themselves as "gatekeepers," to guard and protect the physician from tasks that will only take up more valuable time. They may believe that "rules" or "law" won't allow the physician to sign such a document and may refuse you access to the doctor.  Most physicians will sign such a letter if it is brief, to the point and factual.

What if I can't find a doctor who wants to do the letter?

Some physicians are specialists who perform records reviews and/or Independent Medical Examinations and provide opinions. These doctors usually do a very good job with writing nexus letters, assuming that you can't get one some other way. These independent physicians can charge from about $1000.00 and up, depending on the extent of the services. You must pay that fee in advance with no guarantee that the physician will agree with your theory or that you will get benefits. The Independent Medical Exam doctor does not treat or prescribe and provides only a records review and report.

Conclusion

The importance of the nexus letter can't be overstated. In many situations the nexus letter from an expert is the only evidence that will tip the scales in your favor. 

[Buck52]

Great information from doc25

[Berta]

Can you scan and attach the denial here with the evidence list? Cover C file # ,name before scanning it.

"back pain" is a generic term- everybody has back pain at some point in their life.

What is the medical diagnosis ?

What I think is missing an inservice nexus ( the inservice cause) of the back pain, treatment records showing it is chronic.

"Lastly, I included in my FDC package 3 buddy statements from family members and co-workers indicating how my lower back has affected my life and job and how it has manifested into depression due to chronic pain."

Buddy statements from members in your unit would have more clout, but also you need to find in your SMRs ,proof of any inservice nexus (link, cause) to your back pain.

This did not rise to the level of a Fully Developed Claim.

 

[doc25]

On 5/30/2019 at 10:22 PM, USMC_SawGunner said:

Apologize for the length(a lot you can just skim over) but I want to put this all out there because I am stunned right now. After 60 days, my claim was abruptly denied. No C&P exam requested. Please tell me how anyone can possibly defend what you are about to read. I have carefully redacted all personal information about myself or my doctors.

________________________________________________________________________________________

 

Below, I have just copy and pasted these sample entries from my bluebutton report. There are many more examples over the course of seeing my VA doctors for over a year but I just grabbed a few entries to give you a clear idea of what they have been writing down in my file. These are just some of the recent entries as you can see by the date. I also have a medication list that is over 2 pages long of drugs I have tried since getting help from them. I am still continuing to see my doctors and receiving treatment.

_______________________________________________________________________________________

 

Mar 15(VA Psychologist): Diagnosis: Major Depression

_______________________________________

March 15(VA Psychiatrist): Dx: Major depressive disorder, recurrent, severe; Insomnia disorder with non sleep mental comorbidity; adjustment disorder with anxiety

_______________________________________

 

March1(VA Psychiatrist): Dx: Major depressive disorder, recurrent, severe; Insomnia disorder with non sleep mental comorbidity; adjustment disorder with anxiety.

_______________________________________

 

Jan 04 (pain management doctor): Chief complaint: low back pain

 

_____________________________________

 

 

Sep 13 Last year(Older VA Psych who retired): DX: depression, chronic low back pain.

 

___________________________________

 

October 22 Last year(Older VA Psych who retired): DX: Unspecified depressive disorder; unspecified anxiety disorder with panic attack, Insomnia, unspecified.

 

_______________________________________

 

In addition to these notes, I went out and got TWO seperate DBQ's filled out by my local doctors. They are both board certified psychologist.

 

Here are the DBQ's with all personal information redacted:

 

 

https://imgur.com/a/ztSD9SS Private board certified doctors DBQ #1 

 

https://imgur.com/a/XDF4kTC Second Private board certified doctors DBQ #2 

 

_________________________________________

 

Lastly, I included in my FDC package 3 buddy statements from family members and co-workers indicating how my lower back has affected my life and job and how it has manifested into depression due to chronic pain.

 

_______________________________________________________

 

Everything you see above, resulted in this:  https://imgur.com/a/9NmbYMd     60 days and not even a C&P exam request.  

 

My mind is BLOWN right now. How.

 

EDIT: I have worked manual labor construction my entire life, due to how bad the back pain has gotten and now the depression I have been out of work for over 6 months. I will now be applying for food stamps. God Bless the VA.

The DBQ's are not sufficient evidence for a nexus of opinion. They are only good to give the rater a better picture of your symptoms.

If you were not provided a C&P exam, this might fit in as "failure to apply the Duty to Assist".

APPEAL this, because it's well known in the medical community that back conditions, especially chronic pain, can cause mental disorders.

Read this:

https://www.medicalnewstoday.com/articles/314493.php

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)12479-8/fulltext

https://www.practicalpainmanagement.com/resources/news-and-research/international-study-finds-back-pain-mental-health-closely-tied

 

You can provide these articles as additional medical evidence. You don't have to be a medical professional to provide evidence of what's already been researched and linked by actual medical professionals. 

 

[vetquest]

Unfortunately you need an event in service that lead to your back problem, proof of chronic back problems and a nexus tying your service to the back problem.  Without these you will not be able to get service connected for your back and then secondary depression.  You need to search your SMR's for a time when you went to medical professionals after an event that caused your back problems.  Unless you are less than a year of separation you will not win without this.