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

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    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

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LightningFan75

Need Help with an unfavorable C&P for PTSD Secondary to MST

Question

I need some unofficial guidance with my claim for PTSD.  I think I have two uphill battles ahead...I just had my C&P and have received the notes from the exam.  The doctor has completely discounted that the event happened, much less any secondary markers, attributing my trauma to a childhood incident.  His notes contradict themselves on multiple occasions.  He states that I denied any history of alcohol abuse, yet states later in the exam that I disclosed that I started abusing alcohol after the incident.  He also discounted and falsely reported several facts surrounding my time in the service.  He stated I was never in combat, never had foreign service or received any combat medals and to view my DD-214 for more information, yet my DD-214 shows multiple combat medals, foreign service and he his report lists my service dates where i received combat pay and hostile Fire/Imminent Danger pay.

His notes are mostly snippets copied and pasted from my past appointments that support his denial, but he leaves out all of the relevant parts of my session.

He never looked me in the eyes and stared at his clip board the entire time

He said I started therapy after I lost my job and that I lost my job in April, when in fact I was therapy months before I lost my job which was 7/16.  I told him all of this and he reported it wrong.

He also put down: 

On the SIMs, a measure of symptom validity, the score of 37 indicated significant symptom exaggeration/over reporting.

On a PTSD symptom validity screen, the score of 25 indicated significant symptom exaggeration/over reporting.

Basically he's calling into question my integrity and makes no reference to my MH sessions with my provider, who never once questions my honesty in our sessions.

My test scores from my MH sessions are:

PHQ-9 (Depression): 23

PHQ-9 was administered and score indicates severe depression.

(RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-19 Moderately severe;

20-27 Severe)

GAD-7 (Anxiety): 19

GAD-7 was administered and score indicates severe anxiety. (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-21 Severe)

PCL-5 (Posttraumatic distress): 64 (very severe symptoms reported)

PCL-5 was administered and the score is > or equal to cutoff score of 33 and may be consistent with a diagnosis of PTSD..

 

That leads me to my next issue...my MH provider continually throws out the term PTSD in our sessions, has started me on a treatment plan that consists of BOTH MST and PTSD therapy and yet WILL NOT put PTSD as a diagnosis.  Instead I'm diagnosed with:

DIAGNOSES (per chart):

Major depressive disorder, single episode, moderate

Anxiety disorder, unspecified

 

On top of that my VA psychiatrist put contradicting statements in my last exam:

DIAGNOSIS:

Mental Health Diagnoses and Relevant Medical Conditions:

Unspecified Trauma-Stressor-related Disorder r/o PTSD

Significant Psychosocial and Contextual Factors: MST (Sexual assault)

CASE FORMULATION AND RESPONSE TO TREATMENT:

35 y/o female veteran with anxiety, depressive Sx's and significant

clinical

distress since index trauma, in 2011. High suspicion for PTSD. No prior MH treatment.

 

So he in essence ruled out PTSD and then stated he had a high suspicion for PTSD.

 

I apologize that these thoughts may seem all over the place, but my treatment notes are a mess and the C&P examiner added 112 pages to it with mostly copy and paste, so it's hard for me to make sense of and I'm very hesitant to upload personal information.  I just don't know what to do when MH provider says I have PTSD from MST, puts me in treatment but won't diagnose me, and then a C&P appointment with a doctor who acted like he had better things to do and went mostly off my test scores and didn't really listen to a word i said since his notes are riddled with inaccuracies.

 

 

 

 

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hi  LightningFan 

I would do 3 things. First, since your therapist is in you corner, I would contact him/her and ask  to have an "addendum" note to your last session progress notes that confirms that it didn't happen in Dubai but in X. If he can ID were he original stated were it happend, so much the better. His note will state that you are upset and have anxiety about possible confusion because of a clerical error. Second, upload that note yourself into your records i.e. get it in there twice. Third, I would secure message/contact your last therapist that made the error and respectfully explain that it didn't happen there and to please correct the record. Get that reply and enter it into your record again. If you have a copy of the response from your doc, include it. Be nice. Don't get upset, just ask politely to correct it because it distresses you that there is an inaccuracy. Most of the time these error happen because we are human and we don't communicate and record things accurately. Another point; If it is at VES, bring copies of your records; the VA is notorious for not forwarding all your records to a contractor.

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LightingFan, I would contact your senatorial or congressional offices or all of them.  They take a very dim view of a constituent losing their home due to the VA taking forever to adjudicate a claim.  It should help.  I also might contact a media outlet and tell them what you were told by the VA.  The media only cares about you as long as your story can sell print but it might help.  Keep us apprised of how this is moving.

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23 hours ago, GBArmy said:

hi  LightningFan 

I would do 3 things. First, since your therapist is in you corner, I would contact him/her and ask  to have an "addendum" note to your last session progress notes that confirms that it didn't happen in Dubai but in X. If he can ID were he original stated were it happend, so much the better. His note will state that you are upset and have anxiety about possible confusion because of a clerical error. Second, upload that note yourself into your records i.e. get it in there twice. Third, I would secure message/contact your last therapist that made the error and respectfully explain that it didn't happen there and to please correct the record. Get that reply and enter it into your record again. If you have a copy of the response from your doc, include it. Be nice. Don't get upset, just ask politely to correct it because it distresses you that there is an inaccuracy. Most of the time these error happen because we are human and we don't communicate and record things accurately. Another point; If it is at VES, bring copies of your records; the VA is notorious for not forwarding all your records to a contractor.

Thank you!  That's a great idea...the only sticking point I see is that I've been bounced around to 3 different doctors and a handful of "phone consultations", so I'm not sure which doctor made the mistake and I can't find it in my Blue Button records (though to be fair there are about 100 pages of notes).  I will, however, ask my PTSD doc (the ONLY MH provider I've been to that seems to want to help) to put in my session notes that I'm very upset and anxious about the mistake and have him confirm where it actually happened.  He told me that he should have the letter he's writing ready for me at my session tomorrow...once I get it I'll upload it to see if it's even worth submitting.  I have a feeling he's going to play it very safe and not write a NEXUS letter per se.

I already have my book of records ready to go for Friday.  

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22 hours ago, vetquest said:

LightingFan, I would contact your senatorial or congressional offices or all of them.  They take a very dim view of a constituent losing their home due to the VA taking forever to adjudicate a claim.  It should help.  I also might contact a media outlet and tell them what you were told by the VA.  The media only cares about you as long as your story can sell print but it might help.  Keep us apprised of how this is moving.

I just submitted my ROI form to my congressman, who funny enough had an office at the Orlando VA until recently when they kicked him out.  I think they were mad that he had an open door policy for veterans and was sort of a champion for disability benefits.  He's also held several town hall meetings for vets to discuss what they're going through with care and claims.  (MST is apparently a VERY big sticking point with him and the treatment here)

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Merry Christmas Everyone!!!  and Happy Holidays for those who don't celebrate!!!

 

I had a Christmas miracle happen!  I logged into EB on the 26th and my rating went from 70% to 90%!!! They approved my PTSD at 70% and my shoulder that I've been fighting since forever at 20%. 

Now the bad news...the effective date of my PTSD was 12/13/2019 even though I submitted my supplemental on 6/13 and have been claiming mental health issues since 2017.  Also I first claimed my shoulder in 2017 and they denied my claim without a C&P exam even though I had a report of 2 accidents in my MR.

Can I appeal the date of my shoulder since I was never given a C&P and had to gather the evidence on my own? And can I appeal the date of my PTSD since the C&P exams I had from the beginning reported my statements in error?  The doctor from the very last exam I had (on the date of the rating 12/13) was wonderful and took the time to go through my past exams and listen to me very careful and set the record straight correcting all of the false statements the previous doctors made, and gave her own opinion based on our discussion coupled with the letter from my current VA MST therapist.  

See my very first claim of PTSD from 2017 has been in deferrment until just a few days ago so technically shouldn't it be still be considered open?  So shouldn't I be able to request a back date all the way to the date of that first claim?

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