Complicating Questions

What complicates that question though is if you don’t use, let’s say for example, subjective symptoms like headaches and tinnitus in the evaluation of TBI, then you can rate the veteran separately. So, if the veteran’s headaches, for example, are in a pattern analogous to migraines and warrant perhaps a 30% evaluation, you may assign the initial TBI evaluation under 835 and then assign a separate 30% for the headaches because you didn’t use it in the evaluation of the cognitive impairment. Sounds a little complex, doesn’t it?

Complexity of the VA System

Bill: Yeah, well, you know, you get to talking about the VA, it all becomes very complex unless you’re dealing with it every day and you’re up to date on everything and the changes they make. But the normal veteran is certainly in a world of hurt. They need some proper expertise when facing the VA because, like you say, sometimes it takes other people observing you to say, “Hey, this guy here, he’s making claims on the wrong thing; this looks like something else to me.”

Dr. Bash: Yeah, and that’s not exclusive to TBI or the topic of TBI. Dr. B and I worked together on many cases for several years with multiple sclerosis, and patients would have alternative diagnoses for symptoms that manifested during service or shortly thereafter. Only someone with the appropriate knowledge and motivation, obviously, would look at this in retrospect and say, “Hey, wait a minute, this started back here in the service records; I see it.” So, it’s important to have good medical evidence and a motivated and sincere representative helping you.

Importance of Representation

Bill: And particularly folks with TBI and emotional disorders that aren’t always able to act in their own best interests. The impairment might impede their ability to express their claim, and that’s always been trouble.

Diagnosing TBI

Jay: Dr. B, what kind of medical test is required to diagnose TBI?

Bill: The manual doesn’t specify the exact testing. I’ll leave it to Dr. Bash to describe what manifestations he looks for to make the diagnosis. The manual requires that for adjudication purposes, a diagnosis must be made by a physiatrist, psychiatrist, neurosurgeon, or neurologist. A general clinician can evaluate TBI, but only if they have completed VA’s training module on TBI and only if the diagnosis is already on record made by one of those specialists. So, the VA has imposed some more stringent standards on who can conduct the exams and opine, which is probably a good thing.

The Complexity of TBI

Dr. Bash: We’re neuro-radiologists, the orphan children. There are only a couple thousand of us compared to 20,000 neurologists. When they wrote that, they should have included us because there are some obvious things we can see on images that help with that. But it’s complicated; sometimes it takes the whole group to sort out what exactly is going on.

Jay: It takes a lot of research to nail it all down. If you have a TBI injury and it’s not showing any lesions, that seems like a tough case. How on earth are you going to prove that up?

Proving TBI

Bill: Sometimes it’s a diagnosis of exclusion, where you rule out other conditions like MS, brain tumors, and toxic exposures. Then you hear this history of trauma, symptoms fit, and you make a diagnosis that way.

Jay: There should be a way to measure it, but the brain is the most complicated thing we know. We have neuro testing, rapid movement testing, high movement brain scans, and a lot of stuff we can do, but nothing tells us exactly in every case if it’s TBI. A lot of medicine is in the gray zone.

Historical Claims and Diagnoses

Dr. Bash: If you have historical claims before the TBI criteria came out, like if the veteran had a head injury and was treated for residual concussion…

Bill: Prior to 2008, diagnostic code 845 had no evaluation other than 10%. If the record indicated complications like paralysis, skull loss, or vision or hearing loss, they were separately evaluated. But the TBI itself, or brain disease due to trauma as it used to be called, was just 10%.

Importance of Proper Documentation

Dr. Bash: I can’t emphasize enough about the diagnosis. If you take your car into a Volkswagen versus a Chevrolet, they’re going to treat it differently. The VA is going to rate it differently. So, our first patient had that diagnosis of amnesia, which was the wrong diagnosis. Now he has the correct diagnosis of TBI. Patients need to make sure their doctor gives them a concrete diagnosis because sometimes when the doctor’s confused, they won’t give you a diagnosis, and you don’t make any progress in treatment or for VA purposes.

Role of Spouses and Observers

Bill: To the spouse or significant other out there, if you’re observing symptoms that don’t add up or make sense, you might have to hold that person’s hand and guide them to get the right help.

Jay: You’re seeing too many things that just don’t make sense. Get to a specialist, a medical specialist of some sort.