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Does anyone have experience with "clinical appeals"?


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On 5/7/2020 at 2:24 PM, GBArmy said:

slangpdx I'd do three things. First I would use secure messaging on ebenefits and request authorization for the alternative test. You want to get it in writing. Put the company info in there as well. The second is I would put in a IRIS request on va.gov (under the "contact us" button.) Ask for a email response. Lastly, I would call the VAMC medical director after waiting 4-5 days for #1. Sqeeky wheel works (sometimes.)

Tx for response.  I sent a detailed message through VA.gov.  Will follow up as suggested (call primary care to ask how to reach medical director?)  I tried using the messaging at ebenefits but you have to "upgrade to Premium" to send a message which then wanted to run a credit check - at which point I backed out because my credit history is none of the VA's business or that of the no doubt private company that is running this website.  How long has this been happening and why do veterans not protest?

In any case the background and subtext of this is that I got the test done three years ago ex VA for about $300 including doc visit.  I showed the negative result to the head VA doc in the department who still scheduled me for surgery to remove something "suspicious" seen on cystoscopy - which the pathology report then showed was negative, just as the FDA approved urine test predicted.  So the urine test was correct and the doc's judgment was wrong, while I was subjected to the risk of surgery because of the decision.  A vet in line ahead of me for surgery that day was having scar tissue removed that was blocking his ureter and causing urine to back up into his kidney due to excessive prior surgery, requiring yet more surgery on this occasion to clear it.  These procedures are not risk free.  I have decided I am going to pursue this to whatever level is needed because my own medical records prove this approach is safer and more reliable than what the docs are currently doing. (Not to mention the pandemic issue of people going into the hospital at this time, which they should be trying to avoid where possible.)  This a medical philosophy issue and there is no reason why they can't accommodate this request.  Two companies the VA works with in fact do the test, and I gave the phone number of one of them in my message while naming both. 

I mailed a copy of the test result back at that time to three VA docs including my primary care doc and the one who did the surgery, asking that it or a note about it  be put in my medical history.  It never was, and the medical records office said they could not scan it in (don't know if that is true). 

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Well, Im not sure how many hoops I would jump through to get VA to pay for a test that costs 100.00..the obvious answer here is to go to a private doc and get the test done, if you think its all that

On 5/8/2020 at 1:37 PM, broncovet said:

"Well, Im not sure how many hoops I would jump through to get VA to pay for a test that costs 100.00..the obvious answer here is to go to a private doc and get the test done, if you think its all that necessary. "

The cost for the test plus private do visit would be $300.  I had an order in at a medical college which was then cancelled due to the pandemic and they will not put it back in.  So have to start over.  Requested order for covid antibody test, which doc could not place to
Quest after a week of faxing and calling, so left hard copy at clinic which I then picked up and hand carried to Quest for blood draw.  This in an era of phone internet and fax for a doctors order.  Of course VA would not order it.

This test I am requesting I had done previously and VA refused to incorporate it into my records, so I am pursuing this to get them to order the test so it  will then have to be acknowledged as internally generated.  See my response to GBArmy at this topic.

 

 

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On 5/7/2020 at 3:23 PM, kanewnut said:

Try a search for "VA clinical appeal form". I found an interesting document from 2016.

I searched and only show up claims. Can you not have posted that link?

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If you search the BVA chairmans report, you will see that "compensation claims" is not the ONLY reason Vets appeal to the BVA.  

On the 2019 BVA chairmans report, it shows the board processed 371 medical claim appeals in addition to 32,000 compensation appeal  claims.  (page 32)

There were also 2 insurance issues, and many more.  See for yourself.

https://www.bva.va.gov/Chairman_Annual_Rpts.asp

I suggest people read the BVA chairmans report, but most people dont.  It has a wealth of information.  For example, if you appeal to the BVA, only 20.7 percent of those are denied.  The rest are awarded, remanded or "other".  Im not sure what "other" means, but it may include if the Veteran dies and no one filed a substituiton of claimant.  

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