Esophagus, spasm (cardiospasm) rated "with" IBS, GERD instead of on it's own?

[flow1972]

So, I am SC'd on GERD 10% and IBS 30% which they grant at a 30% combined rating since (according to the VA) codes 7319 and 7346 (Hiatal hernia is what they use for GERD) fall in the inclusive rating categories according to this:

Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.

I would argue that, that's not what that says..

It actually says codes 7301 - 7329 are inclusive and then

7331. 73342, and 7345 - 7348 are inclusive

which would actually mean codes 7319 and 7346 are in their own categories and should be rated exclusively.  

 

However, my actual question is about code 7204 Esophagus, spasm (cardiospasm).  I submitted a claim for this, but it was not rated separately.  Instead, I was given:

Evaluation of IBS and GERD with esophagus spasm of (cardiospasm) (claimed as esophageal condition):

The evaluation of IBS and GERD with esophagus, spasm of (cardiospasm) (claimed as esophageal condition) is continued as 30 percent disabling.

We have reviewed the evidence received and determined your service-connected condition(s) hasn't/haven't increased in severity sufficiently to warrant a higher evaluation.  We have continued a 30% evaluation for your IBS and GERD with esophagus, spasm of (cardiospasm) based on:

-Abdominal distress

-Alternating diarrhea and constipation

Additional Symptoms Include:

-Disturbances of bowel function

-Frequent episodes of bowel disturbance

This is the highest schedular evalution allowed under the law for IBS. (38 CFR 4.114)

A higher evaluation of 60% is not warranted unless there are symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. (38 CFR 4.112, 38 CFR 4.113, 38 CFR 4.114)

A 10% evaluation would be warranted for your GERD with esophagus, spasm of (cardiospasm) (claimed as esophageal condition) based on:

-Pyrosis (Heartburn and/or Reflux)

-Substernal pain

-Regurgitation

-Persistently recurrent epigatric distress

A higher evaluation of 30% is not warranted for hiatal hernia unless the evidence shows persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. (38 CFR 4.114)

Ratings under diagnostic codes 7301 to 7329, inclusive, 7331,7342, and 7345 to 7348 inclusive will not be combined with each other.  A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with the elevation to the next higher level evaluation where the severity of the overall disability warrants such evaluation. (38 CFR 4.114)

 

So in reading that, I do not  see how 

7204    Esophagus, spasm of (cardiospasm). 

                  If not amenable to dilation, rate as for the degree of obstruction (stricture).

falls in to that rating criteria.  Does anyone have any experience in getting a separate rating for 7204? I'm now at 92.23% SC'd with 1 rating on appeal and an increase on remand.  Both of which (if granted at what the reg actually says) would kick me to 95.29% (or rounded to 100).  This one, I really expected to be at 30% on its own...so I'm confused as to why it was rolled in to another rating.

 

[broncovet]

  I apologize that no one answered your post earlier.  No, I have no experience with "throat issue claims".  

However, I do see that a lot.  It sounds like you have done your homework and have all the DC's.   

You did not indicate the date of the decision, but I will guess you are in the one year appeal period.  

File a NOD..it sounds like you can cut and paste your explanation, above, into the NOD as to why you deserve more. 

The compensation for 90 percent Vets is just  $1862, while just 10 percent more brings it "almost double" to $3106.  

Of course, I dont know if you are working, but TDIU will also net you 3106 for a single Vet, if awarded.  

As always, keep the Caluza elements in mind, assuming your condition is NOT secondary to one of the others, and I dont know that, either.  

Get a copy of your file (or use VBMS access) .  

You "may or may not" need an IMO, to seperate out those symptoms.  

Remember, pyramiding prevents VA from compensating you twice for the same symptoms.  So, if "pain in the throat" is present with one condition, you can not also get compensation for the symptom of "pain" on both conditions.  You need to seperate out your symptoms.  

Edited October 11, 2020 by broncovet

[flow1972]

Thanks, broncovet.  Pretty sure I was able to answer my own question by reviewing the regs.  Background is...I'm already SC'd on both IBS and GERD (as hiatal hernia).  Both of those are SC'd as secondary to PTSD.  I submitted the claim for esophageal spasm on its own as a secondary to GERD.  All elements of SC have already been met with the primary conditions.  They didn't "deny" the connection only that it was already included in already rated conditions.

What I've found is that the symptom list for the schedule rating under hiatal hernia doesn't use the words "esophageal spasm", but it does use a different medical terminology that "means" esophageal spasm.  Dysphagia.  This is where the VA apparently expects us to be MD's.  So, they included that as a "symptom" of an already rated condition instead of as a "condition" on its own.  <insert eye roll>  Whatever.

As for a NOD...I'm in the new system, so I don't see any ability to do that.  You get 3 choices...appeal for higher level review with no new evidence, appeal for higher level review with new evidence, or appeal to the BVA directly....that's pretty much it.

As for getting a copy of my file...I've found that to be nearly impossible.  I have copies of everything "I've" submitted and all decision letters, but I have not been able to get ahold of any C&P's done by VSA.  How do I use my VBMS to access?

[Carl the Engineer]

"The compensation for 90 percent Vets is just  $1862, while just 10 percent more brings it "almost double" to $3106"

Bronc,

I know you know this, but it is fun anyway.  A Veteran rated at a real 90% needs a 50% rating or more to get to 100%.  90% is the hardest hole to get out of.  As of 2009. in Wisconsin, there are around 60,000 disabled Veterans, but only 411 of us at 90%, the lowest of any category by a long shot.  I as an example, have a real score of 91, and need a 40 or bilateral of 30 or some combination, etc.  Which is hard to achieve when my highest single rating is 30%, LOL..

Anyway, not being critical at all, just having fun with VA math..

Hamslice

 

[Tbird]

Caluza Elements

[flow1972]

2 hours ago, Hamslice said:

"The compensation for 90 percent Vets is just  $1862, while just 10 percent more brings it "almost double" to $3106"

Bronc,

I know you know this, but it is fun anyway.  A Veteran rated at a real 90% needs a 50% rating or more to get to 100%.  90% is the hardest hole to get out of.  As of 2009. in Wisconsin, there are around 60,000 disabled Veterans, but only 411 of us at 90%, the lowest of any category by a long shot.  I as an example, have a real score of 91, and need a 40 or bilateral of 30 or some combination, etc.  Which is hard to achieve when my highest single rating is 30%, LOL..

Anyway, not being critical at all, just having fun with VA math..

Hamslice

 

I hear you.  It's mind-numbing.  I am a nerd, so I actually have a spread sheet I keep track of "current ratings" with a formula to give me what my "actual score" is using "VA Math".  I'm currently at a real score of 92.23

Condition	Connection	Total Rating
Raynaud's Syndrome	40	40
Arythmia	30	58
IBS/Gerd	30	70.6
PTSD	30	79.42
Cervical Strain With Degenerative Arthritis of spine	20	83.54
Radiculopathy Sciatic Nerve Right Lower	20	86.83
Asthma	10	88.15
Skin Condition	10	89.34
Tinnitus	10	90.41
Radiculopathy Sciatic Nerve Left Lower	10	91.37
Degenerative Arthritis Of Spine	10	92.23
Allergic Rhinnitis	0	92.23

 

I have a new claim in for nerve paralysis as secondary to the Cervical Strain With Degeneration.  If I get that as Moderate Right and Mile Left CTS under..it should kick me just over 95% which will get me rounded to 100.  I also have a request for Higher Level Review on the Skin Condition since they ignored the prescriptions I submitted with that Claim, and I didn't do the math "for them" to show more than 6 weeks in a given year.  It should have been 30% based on that.  Plus, I submitted a request for increase for Asthma to 30% based on the doc putting me on inhaled steroids...should have pushed it to 30%, but I think they've denied that increase...waiting on the stupid decision letter so I can read their BS reason for that.  It's literally in the reg based on medication...and they didn't include that in my last C&P..so they apparently got a DBQ from a Doc that didn't examine me..to base their idiocy on and force me to appeal.  They make me crazy.

 

[broncovet]

Flow, I would have advised for you to "get your appeal to the BVA as soon as possible", and likely eliminate HLR or SCL, for the following reasons:

At the BVA your odds of a denial is about 20 percent.  The rest are remanded or awarded.  Source: BVA chairmans report, scroll down to about page 32:  https://www.bva.va.gov/Chairman_Annual_Rpts.asp

However, VARO's (which include HLR and SCL) are only awarding about 20 percent, that is, 80 percent are denied.  So your odds are much more favorable at the BVA.