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Private Doctor Nexus Statement


deedub75
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Question

Hello All,

I'm new to the forum although I've been on the site to read comments in the past.  

 

 

I've been battling the VA for years trying to get SC for my knees and my back.  I am claiming bilateral knee tendinitis and and bulging disc in my lower back secondary to my service connected right ankle injury and bilateral pes planus.  Every time I appealed, the VA kept sending my claim back to the same NP that keeps denying me over and over.  Every time new information was presented she would come up with a different reason to deny me.  She just keeps doubling down on false information.  First, she said I had a normal gait.  I provided a copy of my exit exam stating I had an abnormal gait.  She then said my gait wasn't bad enough.  My case ended up at BVA where the judge remanded it basically saying that the examiner was ignoring my abnormal gait and other issues.  She then denied it again saying that my age and weight was the cause of my knee and back issues.  I have put on weight but when I originally filed these claims and attended exams I was around 170 pounds or so.  

A couple of months ago, I decided to ask my orthopedic surgeon if he'd be willing to write a nexus statement for me.  I asked him if it was possible that pes planus and a bad ankle could cause knee and back issues and he said it absolutely can.  He couldn't believe that the VA would say it was impossible.  I found a nexus statement online and actually wrote it for him.  I gave him a handful of my records to review showing that the VA had diagnosed me with knee and back issues so he was comfortable saying that he revived my VA records.  I sent this in as a supplemental claim and got a call today from a contract company for a C&P exam.  I was kind of surprised that exams were ordered but I figured that maybe they want to find out the current severity of my conditions.  The person did mention medical opinions which have me a bit worried now.  

I believe I am seeing a general practice nurse practitioner.  If this NP says my knee and back issues are less likely than not caused by my SC pes planus and right ankle, could she really override what my board certified orthopedic surgeon says?

 

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A specialist  like a board certified orthopedic surgeon 

will trump a N.P Anytime, stay away from this N.P.

It only takes me once when someone like a NP says in their opinion so so is less likely not caused by or your S,C, Condition  or your condition & does not warrant a rating..I'd never go back to someone like that  especially when I had other evidence thats says I do.

Submit the certified board orthopedic surgeon opinion.  your evidence won't get any better than that.

Edited by Buck52
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What Buck said above is true!  Now you also need to be ready for the reality of what might happen.  They could totally ignore anything you give them.  They can go off of what the NP says and not say a single word about any other paper work.

This is sometimes the truth of what happens and be ready to appeal if/when this happens.  

I had a slam dunk if they would have read my paperwork!  now years later I won but it was a fight!

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Whatever you do, don't give up! If it takes 20 years, don't give up!

Sgt. Wilky

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THe VA ignored my IMOs it took me going to the BVA to get the win. Even though it was my money already I still enjoyed the nice retro pay when it came in.

Remember the only time you lose is when you give up, don't you can win your claim. 

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They ignored my VA doctored and private MDs IMOs unti it went to the DRO but I also stated in my appeal that my medical va doctors and private IMOs  experience equaled 150yrs of experience to 1 DO with 15 yrs.  Plus I included every rule or regs that applied to a equal or greater than evidence.  I also complained that the examiner was not aware of my condition and refused to accept additional medical treatise to education himself on my condition or review the IMO or VA specialist statements.

complain about it being the same examiner (np) who has less knowledge and expertise then a specialist.  Put in in writing!

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Ruby you are actually very fortunate that the DRO listened and considered your evidence. Usually, they would deny and you would have to push it toe the BVA to get it right. Good for you.

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Would like to think I worded  my case properly and throw everything at them. There wasn’t a medical treatise or a medical opinion that I didn’t have.  They imos were from world renown physicians.(I was lucky).  I think any time you can prove your drs, IMO have more knowledge then time at any level the VA examiner has it’s a win.  Your 100 years or expertise far out cedes the va 10 yr examiners base knowledge-significant

theyre  refuseal to accept the info to make them knoledgeable showed disdain /laziness for the vetereran. Nor would he read the medical treatise. I had at least fifty article or cases and the rules that applied to the eveidence ,such duty to assist. The DRO read my case @nd I won.  He only kind of understood but enough to figure I made my case.  

i took the denial apart word by word.always demand a hearing in person.

good to anyone appealing.

Ruby

 

 

 

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Dustoff I tend to agree with you. The only time I would think it would be a good move to go for a HLR is if it is drop dead obvious that the evidence is in the DBQ/doc's diagnosis and the rater just plain missed (or ignored it). If it is again denied, you just go to BVA with no additional evidence. But you're right; the DRO is just going to rubber stamp the decision if there is any doubt whatsoever 9 times out of 10. They just figure the average Joe isn't going to try and appeal again, so they can save $.

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Just my 2 cents  I agree with dustoff and GB Army

Long ago and far away  in these old common labor shoes I' turn the world all which away just because you ask me to...  

Huh what hun? just an old Waylon Tune   Ok back to the VA Claims process ....😊 Long ago  the raters were bad about not reading further in out records and do miss the veteran crucial evidence...or not read enough of the veteran most critical part of his evidence that causes 90%of the denials...this starts the appeal process, I would hope they are getting better with this new AMA system kicking in.

However having a dry review of your records is never a good thing , dry review is having a DRO look at your records to make his decision, without the veteran present.

Also its just a matter of the luck of the draw so-to-speak  about the D.R.O. (Decision Review Officers) Hearing , some DROs  are ok and do all they can to help Veteran , some are not ok .THEY TEND TO HAVE A ''POWER '' ISSUE.

So in my humble opinion it depends on what type of DRO the veteran will get?

It's all a crapshoot,  kinda like when we go to our C&P's  That meeting is the most important as for as adjudicated our claims ,  what type of Dr we get determines mostly on the outcome of the exam. 

I also think it depends on your case as to what a veteran needs to do and who he NEEDS  sees, sometimes more than other times a veteran is better off heading straight to the BVA.After being denied.

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1 hour ago, Buck52 said:

Huh what hun? just an old Waylon Tune   Ok back to the VA Claims process ....😊 Long ago  the raters were bad about not reading further in out records and do miss the veteran crucial evidence...or not read enough of the veteran most critical part of his evidence that causes 90%of the denials...this starts the appeal process, I would hope they are getting better with this new AMA system kicking in.

Buck, if I can remember I think they used to call this TOP sheet ratings.  Long ago I decided to copy the most important evidence in my records to send along with my claims. I have multiple documents in my file but I wanted VA to know I knew what was in my file. I have won and lost service connections but for the most part most of my claims were granted. The really good thing is I recently won a CUE claim on one of my original claims because I knew VA had date stamped my evidence but never adjudicated it. Back then my C-file was very small but it has really grown to several volumes but never give up.

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Pete 992

I totally agree with you my friend.

I think its a good thing when they converted our C-FILE To the digital CD Form  sure makes it better and easier to find things now.

But it has its bad faults to because when they converted over if the machine they used could not read a copy that was in the c-file  they left it out.and shredded it..some times  light pencil lead will not copy over and a lot of good medical notes  & evidence has been lost, that's the only bad thing

I need reading glasses to read  but on the new CD  C-FILE I can increase the letter size and that makes it so much easier.....for me anyways.

Edited by Buck52
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I’m fortunate that I leave near a VARO, I took my claimed and had them date stamped (each piece of paper) some times.  If I needed to file something by mail it was numbered and sent return receipt. 

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Deebbud,

the section your looking for 3.159 (5/08) duty to assist.

1. Competent. Medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in MEDICAL TREATISE. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses

i always wrote see section etc. duty to assist then I would type that section, number, it as evidence and provided a copy.  I did this because no one could say oh I didn’t know, if it went to the highest court every piece of evidence would be in my file to support my claim.

 

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Buck,

if the VA acknowledge they recieved a claim but never adjudicated the claim is that a cue. 
 

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Dust off,

I have a complete copy date stamped by the VA.

thanks 

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This is like deja vu. I have been fighting with VA for 6 years on two of the same issues. Bilateral Pes Planus and knee conditions. At the 4 or 5 year mark they sent me to a C&P examination, the examiner did a horrible job administering the exam. Me not knowing I could challenge the exam, I went out and had an Orthopedic Surgeon with over 30 years experience in that field as well as performing VA C&P exams. I had my records in tow, she looked through my records and was amazed that VA would deny with abundance of evidence that was actually on file. Here recently I have appealed that claim again, but this time I challenged that exam, submitted buddy statements and all that. Now everything they need to adjudicate this claim is there. If they deny I go to HLR and if they still deny I go to the Board. 

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Oh yeah and most of my insight came form this forum. Thanks guys. Even if I was not commenting I was reading. That helped me alot to be able to read it and know where to find the information.

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A properly written IMO/IME that follows the IMO/IME criteria here at hadit, 

even if it costs you $$$$, will be the best investment you might ever make.

Pes Planus is well known to cause back, knee and hip problems.*

I know that because I have pes planus.

* and  that is-it is well known in the field of podiatry as well as by orthopedic doctors.

I have custom orthos ,redone every few years. My neighbor was given cheap inserts because his SC knee replacements had made one leg longer than the other one.

His VA Dr said everybody has one leg longer than the other.That is technically true but not everybody had the knee surgery he has had.

I showed him my orthos and he was shocked at the difference between the cheap insoles the VA gave him so he raised a little hell with them and now has better orthos, but I dont know if the VA supplied them or he got them himself at a podiatrist's office.

They say one out of every 3 seniors falls every year.

If they require good orthotics,because foot problems can affect  one's balance, neither Medicare or CHAMPVA will pay for them - I have paid from 350 to 540 bucks for them.

M daughter was due  home from the Mil when my first pair was ready many years ago ( it takes 4-6 weeks).

The podiatrist told me to only start out by using them for a few hours a day. With my baby service woman home, on leave, I forgot what the Dr said and was on my feet for hours cooking and showing her my garden , a new roof I had  , my new PC, and all that stuff, with the orthos still in my shoes.

I woke up the next morning without a chronic back ache I had had  every morning for years.The back ache never came back and all my bone scans over the years had revealed there is nothing wrong with my spine.

Maybe the VA does a better job with foot problems these days, that does not mean however, that some C & P doctor would have a single clue on this type of disability.

These claims can be bolstered by good podiatric internet print outs , that a IMO/IME doctor could use as well, to support their opinions.

 

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On 2/29/2020 at 8:18 PM, ruby said:

They ignored my VA doctored and private MDs IMOs unti it went to the DRO but I also stated in my appeal that my medical va doctors and private IMOs  experience equaled 150yrs of experience to 1 DO with 15 yrs.  Plus I included every rule or regs that applied to a equal or greater than evidence.  I also complained that the examiner was not aware of my condition and refused to accept additional medical treatise to education himself on my condition or review the IMO or VA specialist statements.

complain about it being the same examiner (np) who has less knowledge and expertise then a specialist.  Put in in writing!

I think I originally filed this claim in 2010 and I've been keeping it open since then.  It ended up going to a DRO and then to BVA.  The judge remanded it questioning what the NP's logic and the fact that she seemed to ignore evidence of me having an abnormal gait.  Instead of waiting another 3-4 years for BVA, I jumped into the new RAMP lanes. They sent it back to the same NP and she denied again then saying that my bad gait wasn't bad enough.  I complained in writing about this NP but it did not good.  She's infamous around here with other vets I know.  I asked DAV how to get my claim away from her and they said I either needed a nexus statement from an outside doctor or just let it go back to BVA.  The nexus statement worked in that my claim will not be going back to that VA NP.  They are sending me to have a contract exam and from what I can tell, it appears to be another NP.  VA seems to be doing away with MD or DO exams to cut costs.  So, I can't imagine a scenario where a general practice NP should override a board certified orthopedic surgeon who has been my doctor for the last 5 years and has operated on my fee twice but I've seen it happen before.    

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2 hours ago, Berta said:

A properly written IMO/IME that follows the IMO/IME criteria here at hadit, 

even if it costs you $$$$, will be the best investment you might ever make.

Pes Planus is well known to cause back, knee and hip problems.*

I know that because I have pes planus.

* and  that is-it is well known in the field of podiatry as well as by orthopedic doctors.

I have custom orthos ,redone every few years. My neighbor was given cheap inserts because his SC knee replacements had made one leg longer than the other one.

His VA Dr said everybody has one leg longer than the other.That is technically true but not everybody had the knee surgery he has had.

I showed him my orthos and he was shocked at the difference between the cheap insoles the VA gave him so he raised a little hell with them and now has better orthos, but I dont know if the VA supplied them or he got them himself at a podiatrist's office.

They say one out of every 3 seniors falls every year.

If they require good orthotics,because foot problems can affect  one's balance, neither Medicare or CHAMPVA will pay for them - I have paid from 350 to 540 bucks for them.

M daughter was due  home from the Mil when my first pair was ready many years ago ( it takes 4-6 weeks).

The podiatrist told me to only start out by using them for a few hours a day. With my baby service woman home, on leave, I forgot what the Dr said and was on my feet for hours cooking and showing her my garden , a new roof I had  , my new PC, and all that stuff, with the orthos still in my shoes.

I woke up the next morning without a chronic back ache I had had  every morning for years.The back ache never came back and all my bone scans over the years had revealed there is nothing wrong with my spine.

Maybe the VA does a better job with foot problems these days, that does not mean however, that some C & P doctor would have a single clue on this type of disability.

These claims can be bolstered by good podiatric internet print outs , that a IMO/IME doctor could use as well, to support their opinions.

 

Well, at first they denied my knee and back issues because they denied my pes planus.  Once I got the pes planus denial overturned by the DRO, they again denied my knee and back issues because they said I had a normal gait.  I have no idea how I had a normal gait with SC right ankle and bilateral pes planus.  Anyone who watched me walk could clearly see I had a permanent limp.  I even claimed my left ankle secondary to my SC right ankle but they denied it for the same reason as the knee and back.  When I sent it to the BVA, I pointed out that my exit exam clearly said I had an abnormal gait.  How could I go from having an abnormal gain when I left service, then get SC for pes planus, get an increase in my right ankle disability, and then magically develop a normal gait? The judge pretty much agreed but remained it anyway tell the examiner not ignore the evidence.  The same examiner (NP) then decided that my gait wasn't bad enough to cause knee and back issues then she threw in my age and weight was the likely cause.  I was only like 34 years old and about 170 pounds at the time I filed the original claim.  I get to see an outside contract examiner this time but from what I can tell this examiner is not an MD or DO.  When the contact company called to schedule they said DBQs for back, neck and ankle as well as medical opinions.  I think I will call back and ask what medical opinions they are requiring.  My nexus letter only mentioned knee and back issues secondary to pes planus.  I didn't even ask hime to comment on the left ankle as secondary to pes planus and right ankle.  It could be possible that they are only requiring a medical opinion for the left ankle claim.  My doctor said it's crazy that the VA is denying me because it's well know that pes planus causes knee and back issues.  

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