Introduction

We’re here today to try and inform as many veterans as we can. We’re here with Dr. Bash. Welcome, radio land, TV land, and YouTube viewers and listeners. This is Dr. Craig Bash. I’ve been doing Veterans Medical Opinions for 30 years, and I have dozens and dozens of these radio shows, which we’re going to publish on this YouTube channel, numbered one to whatever. So thank you for listening, and here we go.

Discussion with Dr. Bash

Host: “How are you doing today, Dr. Bash?”

Dr. Bash: “I’m doing good, I’m doing good. We have a couple of updates for you, some new law things maybe, and I’ve got something on CMP exams. Last week, a guy had like seven days’ notice for a CMP exam, right? He wanted me to get a letter for him and a DBQ, so I did that real quick in a couple of days. He tried to upload the new stuff into E-Benefits before the CMP exam, but E-Benefits was blocked for new information. So, the VA was trying to not allow any new information before the CMP exam. What we did is I had him fax it using a VA fax number for the intake center to try and get my stuff in before the CMP exam. So, if anybody runs into that problem out there, if you’re getting blocked from adding information to E-Benefits, use the VA fax numbers.”

Host: “That’s good to know. Thanks for that. I think maybe to add to that, you should probably follow up with a call to confirm receipt and at least make it part of the record that you asked the benefits counselor to see to it that the examiner reviews your evidence before the exam.”

Dr. Bash: “There you go. It won’t guarantee it’s going to happen, but at least you document the fact that you had it, you turned it in, and that you wanted it considered.”

Host: “Yes, that’s important too. I don’t care what you do with the VA, you need some sort of documentation or registration or, you know, a claim number or something, a case number or anything you can get, a confirmation number maybe, something to show that you did make the effort and the material was there.”

New Cardiac Law

Host: “Wasn’t there some new thing about the cardiac law you talked about?”

Dr. Bash: “Oh, yeah. This month, VA has revised the rating schedule for cardiovascular disease. I think it’s basically an effort probably best described as simplification. VA’s rating schedule dates back generations, and legal terminology evolves over time. Understanding improves over time, so VA revises the rating schedule to reflect current terminologies and understandings. They’ve done the same thing to the heart. The old version of the rating schedule had a lot of diagnostic codes for things like arrhythmia, enlarged heart, and even blood pressure. Now, for evaluating the cardiovascular system, VA is taking all these criteria from different diagnostic codes and consolidating them into just a few.”

Host: “The way VA has evaluated the severity of heart disease in the past included more variables than the new version. For example, hypertensive heart disease that results in the limitation of METs is a way to measure the fitness of the heart. It also had a provision where regardless of the METs, if you had an ejection fraction between 30 to 50%, the valuation was 60%. So, you didn’t need the METs if you had the ejection fraction. Now, they’re taking out the alternatives and evaluating everything on just the METs. This means you have to take the stress tests and have the METs measured. The exception is if a doctor says you cannot perform a stress test, then the examiner will do an interview and estimate the stress test based on your activities.”

Rating Schedule Changes

Dr. Bash: “It’s probably going to result in simplification, so it will be easier for the raters to pick an evaluation because they don’t have to consider multiple criteria anymore. I’m not sure if that’s a good thing or a bad thing, but sometimes it would help if I was rating a heart case and had evidence that was inconsistent. Now that option will be gone, and it will be just strictly on the METs for everybody.”

Host: “Bill, on that METs test, if someone has a heart condition and their heart specialist writes a letter stating that they’re not physically able to conduct a METs test, then that should be good enough, right?”

Dr. Bash: “Yes, that’s good enough to say he doesn’t have to do the METs test. Instead, the rating activity now requires a METs estimate by the doctor.”

Host: “The reason I bring that up is because, on my last CMP, the doctor mentioned to me that he couldn’t find anywhere in my records where it said I had ischemic heart disease due to herbicide exposure. He said, ‘I don’t know what I could do for you on your heart,’ although I remember seeing that in my records. But there’s so much stuff in my records, it’d be easy for a doctor to overlook.”

Dr. Bash: “Absolutely. Get the letter from your doctor stating this is ischemic heart disease. That’s not the only alternative. In VA adjudication medicine, we have terms that VA uses that aren’t used in medicine or terms in medicine that aren’t used in VA that create a conflict. One example of that is the term ‘intervertebral disc syndrome’ for spine evaluations. The medical world no longer uses that term, and bed rest is no longer a typical treatment. The criteria established by VA back in 2003 for evaluating this disorder are using obsolete diagnostic words and criteria.”

Host: “So, if the wrong diagnostic words and criteria are used, you don’t get compensated?”

Dr. Bash: “Yes, exactly. But the flip side is that VA made it clear that neurological manifestations should be rated separately from orthopedic ones. So, you might get compensated for radiculopathy, bowel, or bladder disturbances separately from the spinal condition.”

Host: “Regarding the heart diseases associated with herbicide exposure, VA has redefined the medical term ‘ischemic heart disease’ to mean other things like myocardial infarction, atherosclerotic cardiovascular disease, or hardening of the arteries. If the CMP examiner doesn’t find the term ‘ischemic heart disease’ but sees those other terms, they should be accepted.”

Dr. Bash: “Even if the CMP examiner mentioned it to me like that, and I already produced a letter stating I had hardening of the arteries and aortic stenosis, that should have covered it, right?”

Dr. Bash: “It should, yes. But aortic stenosis in itself is more of a valve problem than ischemia. If a condition has a genetic component and is also a service-connected condition, VA should ask the doctor to apportion the degree of disability between them. If they cannot determine what degree to apportion, then you must attribute all manifestations to the service-connected condition.”

Conclusion

Dr. Bash: “Back to the METs, they are a measure of oxygen consumption. For guys that are paralyzed or amputees, they might not be able to do much in the way of METs, so VA should go back to older things like arrhythmias and heart size. At this time, VA is consolidating criteria, which should speed up adjudication but may also need to be challenged in court.”

Host: “Bill, how do they actually do the measurements for the METs?”

Dr. Bash: “The METs are measured during a stress test. If the veteran cannot perform the test, the doctor estimates the METs based on activities like walking or mowing the lawn.”

Host: “What about conditions like orthostatic hypotension?”

Dr. Bash: “Orthostatic hypotension could result in a low METs estimate, but the max is 60%. Practically, you might not see very many people ordered to bed rest for that long of a period of time, so they don’t get compensated.”

Host: “That makes sense. What about cases where the ejection fraction is low?”

Dr. Bash: “They are taking that out, which may be challenged in court because ejection fraction is the gold standard for measuring heart function.”

Host: “Thank you all for listening. That ends this show. Now I’m going to zoom off.”