We have a very special guest. His name is Dr. Bash. Many of you veterans know Dr. Bash; he’s also the Veterans Medical Advisor. He provides independent medical opinions and evaluations for veterans’ claims. He’s been doing this for a very long time and is very good at it.

Dr. Bash: How are you doing today?

Guest: I’m good, I’m good.

Discussing the Latest Bash Bulletin

Host: We were going to discuss something on this show. We were going to discuss your latest Bash Bulletin. I guess it was about how to survive a claim in 2019?

Dr. Bash: Yeah, 2019. There are new rules that came out. They’re not letting veterans add much in the way of new evidence. They’re trying to cut back on the evidence we discussed last week.

Host: Yeah, there are a lot of new factors involved. It depends on which road you choose to appeal. When you get denied, you can choose different avenues to appeal. One of them actually cuts off your ability to add new evidence. That’s something veterans need to really look at and understand because if you follow the new appeal system and select it, you can’t add evidence.

Dr. Bash: Yes, that’s called the higher-level review lane, right?

Host: Yes, I think it is. Higher-level review, no new evidence allowed.

Dr. Bash: Yep, that could really hurt a veteran because so many times you don’t get a hold of some of this evidence until the last minute.

Host: That’s right. You may need extra testing, or maybe have a specialist look at it, or maybe medical knowledge changes in the meantime. You have new medical knowledge to help you.

Dr. Bash: Very true, that’s a tough one. I don’t see how one can survive that. That would put veterans out of bounds.

Host: Some veterans might take it because it’s a faster route.

Dr. Bash: I can see that. I’ve known some VORs that went through the RAMP process and their appeals. I’ve known a couple of them that were actually successful in the process because both of them got 10% for ratings that should have been 60%.

Host: Yeah, it’s like trying to knock bowling pins down with a tennis ball.

Dr. Bash: Right, you get a fast review but a minimum rating.

Host: Then the veterans have to appeal that decision and fight to get their correct percentage. It’s just a headache.

Dr. Bash: And if you go to the traditional appeal, or what they call the legacy appeal process now, it’s the same old process. The backlog was several hundred thousand, so I don’t know exactly what it is today. I’d like to get some accurate numbers, but sometimes we don’t have access to that information.

Host: But the BVA is still taking two years, right?

Dr. Bash: Yeah, a two-year wait.

Host: It wouldn’t be that way, but someone in DC decided they were going to put emphasis on getting all these claims done to reduce the actual claims backlog. They got the claims backlog reduced, but at the expense of the BVA because the backlog from claims just transferred from the VA Regional Office to the BVA. Most of the claims are just, I guess, auto-denial.

Dr. Bash: Yeah, now BVA at the next level is supposed to have new evidence. So, that high-level review lane allows no evidence first, then you wait a few years, then you might be able to get some evidence in there, and then you have no decision.

Host: And the other pathway is called the supplemental claim lane, right?

Dr. Bash: Yes, something like that. Those are extra reviews where you put new evidence in. They want to have something that’s pertinent or relevant. New evidence has to be relevant.

Host: Oh yeah, that’s a new word—relevant. It replaces new and material.

Dr. Bash: So, my plan is to try to make sure the veterans have the best claim upfront. Try to frontload this whole thing, get the testing done, get a lay letter done, get a Nexus done, try to get all that stuff upfront. That way, when you get into those lanes, you have a little jump start on it.

Host: Because if you don’t have those claims, something that’s important is the way you identify the claim. It used to be you could write the claim on a piece of toilet paper and put it in, but now you have to specify what your issue is, what your secondary issues are. It’s complicated.

Dr. Bash: Yes, they’re grouping things now, like next group with knees, group with hips—10%. They group all together.

Neurological Conditions and Claims

Host: Here’s a question for you, Dr. Bash. Since you’re a neuroradiologist, say a veteran has a client with neurological conditions, like radiculopathy. Radiculopathy involves nerve effects, and it can cause sensory problems and motor problems in muscles, like in your shoulders and arms. If you lose a lot of muscle mass in your shoulder and arm, and it starts locking up and causing problems, how does the VA rate that?

Dr. Bash: The nerve can cause sensory problems and motor muscle problems. That’s why in the DBQs, they talk about range of motion, sensory radiculopathy, and myopathy, which is muscle weakness. They rate all that stuff. That’s why you see on the DBQ, you have the range of motion and strength testing. A lot of times they go together, but they don’t have to.

Host: It depends on the nature of the injury or condition. Sometimes they don’t rate it correctly. They’ll rate one issue instead of the other, or combine multiple ratings into one rating.

Dr. Bash: It gets into function. You might have numbness in your hands but still have pretty good grip strength. They might rate the numbness and not rate the myopathy, or vice versa. If you can’t open jars, they can rate that as strength weakness.

Host: That would be based on the sensory or the functional issue of the nerve, right?

Dr. Bash: Yes, because if you’re sensory impaired, you can have motor issues but sometimes your sensory is gone.

Host: A lot of things are based on motor because that’s where the schedule was set up for people’s function. If they can shovel, walk, or need a cane or CR, it adds to their rating. But if you have sensory problems such as poor balance, you can still get a high rating for sensory problems because it affects the same kind of function.

Dr. Bash: Yes, it’s a mixture. As usual, the rating schedule is based on function, regardless of whether it comes from motor nerve or sensory nerve.

Impact of Genetics on Claims

Host: The VA is going to start doing genetic testing on veterans to prescribe their medications.

Dr. Bash: I haven’t seen that.

Host: It came out on March 12. To me, it doesn’t look good. There’s potential for abuse. They could claim that a veteran’s heart trouble is genetic because it runs in the family, not service-connected. There’s a lot of room for abuse here.

Dr. Bash: That’s always been a scapegoat for the VA—to say it’s a genetic disease versus an acquired one. But genetics can show susceptibility. For example, if someone has a genetic susceptibility to an anaphylactic reaction and gets a vaccine in service and dies, you could argue that without the service environment, they wouldn’t have died. Genetic susceptibility is involved in many diseases, but those diseases often manifest due to the environment or situation.

Host: If used properly, it could be beneficial, but I see room for abuse. Who will establish the tolerances for this?

Dr. Bash: It’s like a DIC case. If a service-connected condition lent assistance to the development of a disease, the veteran gets credit for it. If the environment made the genetics worse, that could be a way to get around the abuse of the genetic part.

Genetic Testing and Diabetes

Host: Have you heard about the VA’s genetic testing of veterans?

Dr. Bash: No, I haven’t.

Host: They’re going to start doing genetic testing in certain areas and conditions.

Dr. Bash: What’s the purpose? Are they trying to treat diseases better?

Host: Yes, that’s the excuse, but I see room for abuse. If they use it against veterans, it could be terrible.

Dr. Bash: Most diseases are a mixture of environment plus genetics. If the environment made the genetics worse, you could argue that the disease was aggravated by the environment.

Host: You’re right. The VA might use genetics as an excuse to deny claims.

Dr. Bash: Yeah, like type 1 diabetes is pretty genetic, but type 2 has always been considered less so. There might be more of a genetic component than we realize.

Host: Yes, type 2 is more about the pancreas not producing insulin. Type 1 is a bad deal, too. Some people lose limbs and it’s a dreadful disease.

Dr. Bash: If veterans want to win claims, they need to include all relevant information upfront.

Conclusion

Dr. Bash: To win your claim in 2019, get your claim set up correctly from the beginning. Get your doctor to look at different aspects. If you have diabetes, include all secondary conditions like neuropathy, vision problems, and cardiomyopathy. Make sure everything is consistent—lay letters, DBQs, Nexus letters, and medical records. The VA looks for consistency.

Host: Veterans may not be aware that statin drugs contribute to diabetes. Once they get further along and develop diabetes, they can claim that statin drugs contributed to it.

Dr. Bash: Yes, I’ve seen articles on that. Statin medication lines your vessels and allows insulin and sugar to go through. There might be a relationship, but it’s a big deal because drug side effects are real.

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