Secondary Service Connected Conditions & Medical Opinions

Paula Taylor / Abdullah Shamsid-Deen

Fall Conference, 2009

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SECONDARY SERVICE CONNECTED CONDITIONS

WELL-GROUNDED CLAIMS

SERVICE-CONNECTED

NONSERVICE-CONNECTED

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SECONDARY SERVICE CONNECTED CONDITIONS

WAYS TO ESTABLISH SERVICE-CONNECTED CLAIMS

DIRECT SERVICE-CONNECTION

AGGRAVATED PRE-EXISTING CONDITION

PRESUMPTIVE SERVICE-CONNECTION

1151 CLAIMS

SECONDARY SERVICE-CONNECTION 3

SECONDARY SERVICE CONNECTED CONDITIONS

SECONDARY SERVICE CONNECTION

REFERENCE: 38 CFR 3.310

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SECONDARY SERVICE CONNECTED CONDITIONS 38 CFR 3.310 States:

•  I. Disabilities caused by a service-connected

disability will be service connected on that basis•  II. Also, Non-service connected disabilities made • worse by a service-connected disability, IF ...

a. Medical evidence that pre-dates the worsening

establishes the baseline level of the disability

b. Current severity is worse than the baseline,

which is to be deducted from the overall rating•   c. Current medical evidence cannot establish the

baseline 5

SECONDARY SERVICE CONNECTED CONDITIONS

EXAMPLES OF SECONDARY CONDITIONS

Right Knee, Secondary to Left Knee

Lower Back, Secondary to Knee(s)

Lower Back, Secondary to Pes Planus

Sexual Dysfunction, Secondary to PTSD

Depression, Secondary to Occipital Nerve Injury6

SECONDARY SERVICE CONNECTED CONDITIONS

EXAMPLES OF SECONDARY CONDITIONS (CONT’D)

Kidney Failure, Secondary to Hypertension

Other Secondary Hypertension Conditions?

Glaucoma, Secondary to Diabetes Mellitus

Other Secondary Diabetes Conditions ?

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SECONDARY SERVICE CONNECTED CONDITIONS

ESTABLISHING SECONDARY SERVICE-CONNECTION REQUIRES:

Sufficient evidence that a current disability was

caused or aggravated by a “service-connected”

disability Since this is a question of Medical Causation,

competent individuals possessing specialized training and knowledge must to render a “Medical Opinion”

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MEDICAL OPINIONS

MEDICAL OPINIONS 38 CFR 3.159

COMPETENT MEDICAL EVIDENCE MEANS EVIDENCE PROVIDED BY A PERSON WHO IS QUALIFIED THROUGH EDUCATION, TRAINING,OR EXPERIENCE TO OFFER MEDICAL DIAGNOSES, STATEMENTS, OR OPINIONS. COMPETENT MEDICAL EVIDENCE MAY ALSO MEAN STATEMENTS CONVEYING SOUND MEDICAL PRINCIPLES FOUND IN MEDICAL TREATISES. IT WOULD ALSO INCLUDE STATEMENTS CONTAINED IN AUTHORITATIVE WRITINGS SUCH AS MEDICAL AND SCIENTIFIC ARTICLES AND RESEARCH REPORTS OR ANALYSES.

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MEDICAL OPINIONS

COMPETENT MEDICAL EVIDENCE EDUCATION, TRAINING, OR

EXPERIENCE

DIAGNOSES, STATEMENTS, OR

OPINIONS

MEDICAL AND SCIENTIFIC ARTICLES

RESEARCH REPORTS OR ANALYSES 10

MEDICAL OPINIONS

WHEN WILL VA REQUEST A MEDICAL OPINIONTHE RECORD DOES NOT CONTAIN SUFFICIENT COMPETENT MEDICAL

EVIDENCE BUT:

CONTAINS COMPETENT EVIDENCE OF A CURRENT

DIAGNOSED DISABILITY OR PERSISTENT OR RECURRENT

SYMPTOMS OF DISABILITY

ESTABLISHES THAT THE VETERAN SUFFERED AN EVENT,

INJURY OR DISEASE IN SERVICE OR HAS A DISEASE OR

SYMPTOMS OF A DISEASE LISTED IN 38 CFR 3.309, 3.313, 3.316,

AND 3.317

INDICATES THAT THE CLAIMED DISABILITY OR SYMPTOMS

MAY BE ASSOCIATED WITH THE ESTABLISHED EVENT,

INJURY, OR DISEASE IN SERVICE OR WITH ANOTHER

SERVICE -CONNECTED DISABILITY 11

MEDICAL OPINIONS

WHY WOULD VA REQUIRE A MEDICAL OPINION

TO RECONCILE DIAGNOSES

TO DETERMINE THE RELATIONSHIP BETWEEN CONDITIONS

TO DETERMINE THE ETIOLOGY OR NEXUS TO SERVICE-INCURRED DISEASE OR INJURY

TO DETERMINE WHETHER AND TO WHAT EXTENT A SERVICE-CONNECTED DISABILITY HAS AGGRAVATED A NONSERVICE CONNECTED CONDITION

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SECONDARY SERVICE CONNECTION &MEDICAL OPINIONS

REQUEST FOR MEDICAL OPINIONISSUES:

CONTENTION:

AVAILABLE PERTINENT EVIDENCE:

SERVICE MEDICAL RECORDS:

PRIVATE MEDICALRECORDS:

VA RECORDS

OTHER:

REQUESTED OPINION:

NOTE TO EXAMINER-IN YOUR RESPONSE PLEASE:

1. IDENTIFY THE SPECIFIC EVIDENCE YOU REVIEWED AND CONSIDER IN FORMING YOUR OPINION.

2. PLEASE PROVIDE A RATIONALE (EXPLANATION/BASIS) FOR THE OPINION PRESENTED

3. STATE YOUR CONCLUSIONS USING ONE OF THE FOLLOWING LEGALLY RECONGNIZED PHRASES:

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MEDICAL OPINIONS

LEGALLY RECOGNIZED PHRASES Is Caused By Or A Result Of__________

Is Most Likely Caused By Or A Result Of__________

Is At Least As Likely As Not(50/50 Probability) Caused By Or A Result Of__________

Is Less Likely As Not (Less Than 50/50 Probability) Caused By Or A Result Of__________

Is Not Caused By Or A Result Of__________

I Cannot Resolve This Issue Without Resorting To Mere Speculation

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MEDICAL OPINIONS

MEDICAL RATIONALE

IT IS ESSENTIALLY AN EXPLANATION OF HOW THE PHYSICIAN ARRIVED AT HIS OR HER MEDICAL OPINION AND SHOULD CONTAIN, AS A MINIMUM, AN EXPLANATION OF THE PATHOLOGICAL OR OTHER MEDICAL RELATIONSHIP BETWEEN THE CURRENT DIAGNOSES AND THE INJURY IN SERVICE OR CURRENT DIAGNOSIS AND THE SERVICE CONNECTED DISABILITY

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MEDICAL OPINIONS

EXAMPLEISSUE: ENTITLEMENT TO SERVICE CONNECTION FOR

CARDIAC DISORDER, ORIGINALLY CLAIMED AS MYOCARDIAL INFRACTION, SECONDARY TO THE SERVICE-CONNECTED DISABILITY OF ANXIETY DISORDER: OR, IN THE ALTERNATIVE, SECONDARY TO A TOBACCO USE DISORDER, ORIGINALLY CLAIMED AS CIGARETTE SMOKING, SECONDARY TO THE SERVICE-CONNECTED DISABILITY OF ANXIETY.

FACTS: VA AND PRIVATE MEDICAL EVIDENCE OR RECORDS SHOWS THAT THE VETERAN HAD A MYOCARDIAL INFARCTION IN 1995 AND HAS A CURRENT DIAGNOSIS OF ATHEROSCLEROTIC CORONARY ARTERY DISEASE. 16

MEDICAL OPINIONS

EXAMPLE CONT:July 2002-VA Comp And Pen Examiner Opined Less Likely

Caused Or Aggravated By the Service Connected Anxiety

July 2002-VA Psychologist Opined As Likely As Not That The Veteran’s Heart Problems Are Aggravated By His Anxiety

August 2002-VA Psychologist Explained That the Limitation Of Life That Affected The Veteran Because Of The Heart Disease Felt Worse To The Veteran Because Of His Anxiety Disorder. (The Physician Based The Opinion On A Publication By The American Psychological Association That It Was Possible That Heart Problems Are Aggravated By Anxiety)

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MEDICAL OPINIONS

EXAMPLE CONT:

2004: PRIVATE PHYSICIAN DIAGNOSED THE VETERAN WITH CORONARY ARTERY DISEASE. HE NOTED THAT STRESS AND ANXIETY AS A CONTRIBUTING FACTOR TO CORONARY ARTERY DISEASE WAS CERTAINLY A POSSIBILITY, BUT IT WAS NOT ENTIRELY CLEAR, AS IT WAS DIFFICULT TO DOCUMENT

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MEDICAL OPINIONS

WHAT DID THE BOARD DECIDE

CONCLUSION OF LAW:

A CARDIC DISABILITY WAS AGGRAVATED BY A SERVICE CONNECTED DISABILITY

ORDER:

ENTITLEMENT TO SERVICE CONNECTION FOR CARDIAC DISORDER, ORIGINALLY CLAIMED ASMYOCARDIAL INFRACTION, SECONDARY TO THESERVICE-CONNECTED DISABILITY OF ANXIETY DISORDER IS GRANTED

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MEDICAL OPINIONS

PRACTICAL EXERCISE OUTLINE

ISSUES:

REASONS AND BASES FOR FINDINGS AND CONCLUSION:

(MEDICAL OPINIONS)

DETERMINE THE DECISION:

DETERMINE THE ORDER:20

SECONDARY SERVICE CONNECTION &MEDICAL OPINIONS

QUESTIONS

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SECONDARY SERVICE CONNECTION &MEDICAL OPINIONS

SUMMARY

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