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Examples: Rating/BVA Decisions – attachment to Multiple Myeloma presentation of 11-12-15

*Note: BVA decisions are searchable on their website. No names and no claim numbers: just search by condition such as “multiple myeloma”

Example 1: BVA Decision: Denial of service connection for multiple myeloma for ionizing radiation. Report from the Weapons, Space, and Nuclear Safety Division, US Air Force indicated the veteran spent the majority of his career as an Air Operations Officer, Navigator, Electronic Warfare Officer, and Electronic Officer. The veteran claimed exposure to radiation while a crewmember on an EB-66; however, this plane was designed to detect and jam enemy air defense radars.

The primary radiation emitted from electronic warfare equipment is radio frequency radiation (RFR) in the form of soft x-rays from low powered emitters that are common on aircraft. Long-term cumulative effects have not been linked to RFR exposure.

This denial was upheld.

Example 2: BVA Decision: Denial of service connection for multiple myeloma for ionizing radiation.

The BVA noted the Veteran was a Nuclear Weapons Fleet Ballistic Missile Officer and Ships Engineering Nuclear Officer. His records indicated that he had been exposed to a lifetime total of 0.139 rem of ionizing radiation during his period of service.

Private medical records showed the veteran received treatment for multiple myeloma in June 2010 when a bone marrow biopsy was performed.

An August 2011 dose assessment from the Naval Dosimetry Center confirmed the veteran had been exposed to 0.139 rem of deep dose equivalent (DDE).

A report from the veteran’s physician indicated he was the Director of Myeloma and Professor of Medicine in the Departments of Lymphoma/Myeloma at M.D. Anderson Cancer Center in Houston, Texas. He was Board-certified to practice in his specialty. He reviewed the veteran’s Service Medical Records. The doctor then stated the veteran's multiple myeloma was due to his exposure to ionizing radiation during service.
BVA found the private physician’s opinion was more persuasive than the VA Regional Office's opinion. Accordingly, service connection for multiple myeloma was granted.

Example 3 – Agent Orange claim for multiple myeloma.
The Veteran served on active duty in the U.S. Navy from October 1954 to July 1964 and July 1970 to August 1974. The appellant was his surviving spouse, because he died in June 2006.

His death certificate listed the immediate cause of death as multiple myeloma. At the time of his death, he did not have any adjudicated service-connected disabilities.
BVA noted there was no evidence showing the veteran had service in Vietnam; nor was he exposed to herbicides during service.

The Board found that the veteran's multiple myeloma was diagnosed many years after service, and the cause of his death was not related to a disease, injury, or event in service.

The Regional Office denial was upheld.

Example 4 – Claim for increased disability rating for multiple myeloma, rated at 20 percent disabling. Case REMANDED by BVA.

Multiple myeloma was rated at 100 percent disabling from May 30, 2007, and at 20 percent disabling from January 1, 2010. The multiple myeloma had been in remission since 2008. The veteran was also service connected for cancer.

Note: Per current VA Regulations, a rating of 100 percent shall be assigned as of the date of hospital admission for multiple myeloma and shall continue for one year. After one year, if the disease is in remission, the disability will be rated on any residuals found, as determined by a mandatory VA examination.
On the original VA examination (prior to the denial of benefits) the examiner noted the veteran had anemia and thrombocytopenia. He was unable to state whether this was due to the myeloma, despite it being in remission. Accordingly, the case was REMANDED to the Regional Office for a clarifying opinion whether the anemia and thrombocytopenia were from the residuals of the myeloma OR from the treatment for colon cancer.

Example 5 - Entitlement to service connection for multiple myeloma due to herbicide exposure and contaminated water at Camp Lejeune, NC.

The veteran’s claim for multiple myeloma was denied by the Regional Office based on a lack of a link to service. He appealed that decision.

Subsequently, he submitted new medical evidence showing that, while he had no Vietnam service, he was exposed to Agent Orange while stationed at the Subic Bay Naval base, the Philippines from December 1965 to June 1967. At Subic Bay he was a perimeter guard standing near a fence line that had been chemically defoliated. He submitted a statement from a fellow serviceman who corroborated his statements.

Since Subic Bay was not recognized by the Defense Department as a place where Agent Orange was used, the veteran submitted an article showing that New Zealand supplied Agent Orange to Subic Bay during the 1960’s. This article supported his claim.

The record also showed that the veteran spent 723 days at Camp Lejeune. On a VA examination the examiner stated that there was no plausible connection for his diagnosis of multiple myeloma since the calculated exposure dose was several times below the median exposure level. This decision was made prior to April 2010.

In April 2010, the VA Central Office acknowledged that persons residing or working at Camp Lejeune from the 1950s to the mid-1980s were potentially exposed to drinking water contaminated with volatile organic compounds.

Effective September 24, 2014, the VA amended its regulations to pay benefits for multiple myeloma.

Subsequently, the Board determined that service connection was in order for multiple myeloma.

Example 6 – Denial of service connection for multiple myeloma from Agent Orange
A report from the Air Force Historical Research Agency indicated the veteran’s unit, the 42nd TEWS (Tactical Electronic Warfare Squadron) operated from Thailand, not Vietnam.

Since the veteran had no Vietnam service, BVA affirmed the denial of his claim.

Note: One of the last cases I rated was for an Air Force Navigator stationed in Thailand. His service records showed no service in Vietnam; however, his Service Medical Records showed a “sick-call” entry at an Air Base in Vietnam when he landed there. I immediately granted the claim.

Example 7 – Denial of service connection for multiple myeloma

The veteran stated he participated in atmospheric nuclear testing while in Yokohama, Japan. He further contended that he was taken from Yokohama to Hiroshima where he witnessed an atmospheric nuclear test.

However, in conjunction with a prior appeal, the Defense Threat Reduction Agency (DTRA) confirmed on multiple occasions that the veteran was not exposed to radiation and did not participate in radiation-risk activities at any time during service.

DTRA confirmed that he was not exposed to radiation and did not participate in radiation-risk activities during active service. DTRA also confirmed that the veteran's total in-service radiation dose was 0.0 rem. They stated no atomic atmospheric testing was performed in Japan. Rather, the only testing that took place was in Bikini Atoll, Marshall Islands, from July 1 to August 31, 1946. This was more than 2,000 nautical miles from Hiroshima.

Note 1: No diagnostic code for multiple myeloma is found in the Rating Schedule. Thus, multiple myeloma is rated analogous to the body part affected; i.e., cancer.

However, a new diagnostic code, DC 7762 for multiple myeloma has been proposed, and was published in the Federal Register on 8-16-15. Once the allotted time for “Comments” has expired it is expected, and hoped, that the VA will implement this diagnostic code.

Note 2.Entitlement to Non-Service Connected Pension - If there is no evidence of in-service treatment for multiple myeloma you may qualify for Non-Service Connected Pension and receive benefits based on your income. Example, you have multiple myeloma, rated at 100% (but no connection to Radiation or Agent Orange) this will qualify you for Pension. Of course, you must be unemployed.

Caring For Those Who Bore the Battle

Introduction: A few years ago an elderly veteran wrote his Congressman, asking how to file a claim for VA benefits. The Congressman forwarded the letter to me at the St. Petersburg VA Regional Office where I answered it and sent the gentleman an application for benefits.

Afterward, I wondered why this man had written his Congressman when all he had to do was fill out an application and send it to us. Was that too difficult for him to do? But then I thought: if I were him and knew nothing about the VA, where would I start? With all the confusing information out there, maybe contacting his Congressman wasn’t such a bad idea after all.

I remembered hundreds of other letters veterans had written to members of Congress. Why was this happening? I knew the VA claims process was extremely complicated, and I wondered if our fog-shrouded way of doing business was leaving all of these men desperate for explanations written in plain English. Sure, service organizations such as the American Legion (ALG) or Disabled American Veterans (DAV) etc, do excellent jobs helping veterans get their claims processed, but who gives a former soldier a true understanding of the VA process?

As I continued to think about this problem, I remembered visiting an Internet chat room where veterans complained they could not understand what the VA is talking about when they receive a letter from the Agency. In my opinion, this confusion starts with the way the VA writes its letters, and extends to its interpretations of its own rules and regulations. This, in turn, is aggravated by decisions coming down from the Board of Veterans Appeals and the Federal Veterans Courts, all of whom put their own spin on the rules.

I decided to start researching a book and almost immediately found this example: “to establish a right to compensation a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred.”

Confused? I wasn’t, but that’s because I had spent 31 years with the Department of Veterans Affairs (VA), the last five of those as a Rating Specialist (RVSR) on the Appeals Team. Over the years I’d handled all types of claims and was familiar with the bureaucratic jargon used.

The purpose of this book, then, is to help veterans understand the complex system of medical rules and regulations administered by the Department of Veterans Affairs, or the VA as it is commonly called (Note: The Veterans Administration was renamed the Department of Veterans Affairs in 1988).

Of necessity, I will concentrate only on disability claims and the medical evidence needed to prepare an award (or increase) of benefits. That is, I do not touch on healthcare, education, burial, or other benefits except when the law requires a Rating Specialist to do so, which is rare.

It should be noted that the number of compensation and pension claims received each year increases, not only from the Middle East wars we are engaged in, but also from the regulatory additions to such disabilities as post-traumatic stress disorder. Also, Agent Orange regulations have been expanded to include the following: Ischemic Heart Disease, Parkinson’s disease, and Hairy and other B-Cell cancers. All of these additions have resulted in a spike of approximately 350,000 new claims in one year alone.

PTSD and Your VA Claim - Article Published in Marine Corps Gazette and Vietnow Magazine

Like it or not, the issue of post traumatic stress disorder (PTSD) has been around for a long time. It remains particularly relevant to such 20th and 21st century wars as WWI, WWII, Korea, Vietnam, and Iraq/Afghanistan. I say “like it or not” because some medical specialists consider it a bogus claim. In particular, I listened to a class given by a psychologist from a local VA Medical Center. This non-veteran PhD teacher, who couldn’t have been over 35 years old, had the audacity to state that 85% of PTSD claims were fictitious. Coming from a person born during the Vietnam War era, I wondered what did he know firsthand about combat and post traumatic stress disorder? I think if he had been a combat veteran he might have been more sympathetic to someone who’d glimpsed the fires of hell.

PTSD is estimated to run as high as 30% among those veterans who served in Vietnam, and up to 8% for Gulf War veterans. With the recent fighting in Iraq and Afghanistan, which has involved extensive one-on-one street fighting between our soldiers and Iraqi “insurgents,” we may expect to see a sizeable increase in the number of PTSD claims.

PTSD is not confined to male soldiers who were involved in direct combat. During the Vietnam War many female military nurses acquired it, either working with wounded GI’s in field units, or hospitals as far away as Japan and Germany. PTSD also affects women and children, and further encompasses such incidents as disasters, rape, abuse, accidents, torture, and terrorist attacks. The term also includes survivor syndrome among Holocaust survivors; however, this topic is beyond the scope of this article, and is only mentioned to show the extent post traumatic stress disorder can take. In short, any traumatic event or series of traumatic events can lead to PTSD.

While the symptomatology of PTSD has varied little over the years, precise medical definitions have proved elusive. During the US Civil War a soldier with PTSD-like symptoms was said to have “irritable heart” or “soldier’s heart.” In WWI it was called shell shock, the term coming most likely, from the mass artillery bombardments of trench warfare. During WWII and Korea, PTSD assumed the name “combat fatigue.”

During the Korean War the medical establishment, cognizant of the large numbers of soldiers with PTSD symptoms, made a serious attempt to define this disorder, labeling it “gross stress reactions." This was listed in the 1st edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952. The Second DSM Edition of 1968 labeled PTSD a situational disorder. However, it wasn’t until DSM-III of 1980 that PTSD became a subcategory of anxiety disorders. For VA purposes the diagnosis of PTSD was added to the rating schedule on 4-11-80. DSM-IV, published in 1994, refined PTSD further, aided by a subsequent revision in 2000 called DSM-IV-TR.

So, what exactly is PTSD? Basically, it is a psychiatric condition resulting from exposure to trauma or life threatening events, either in the form of combat, or other manifestations as described in the paragraph above. In all cases PTSD involves a traumatic experience involving intense fear, horror, or helplessness. Veterans with PTSD often relive their experiences through flashbacks and nightmares. From descriptions this writer has seen, these can be very terrifying. Often, veterans have difficulty sleeping. Other symptoms include numbing, loss of emotions, and heightened arousal of the nervous system, to include startle reflex. Veterans thus affected with PTSD may feel alienated from others, especially spouses, family members, and friends. Also, they have trouble holding jobs due to an inability to get along with others. Involvement with the criminal justice system is not uncommon. Other manifestations include serious conditions such as depression and anxiety disorders; sleep disorders, to include nightmares; difficulty with concentration; a sense of always being on guard; self-medication leading to alcohol and drug abuse; and even suicidal attempts.

These symptoms of PTSD range from the minimally intrusive to severe, and are oftentimes chronic. Many veterans live their lives in quiet desperation, displaying only mild symptoms. That is, they are able to cope with their past demons. When they reach retirement age, however, their symptoms may suddenly become acute and severe. These symptoms may be triggered by significant events such as the 9-11 disaster in the US, or remembrances of combat, examples of which are depicted in movies, pictures, and anniversaries such as D-Day. Veteran gatherings or reunions may also bring back painful memories of combat.

PTSD as a disorder is often complicated by virtue of the fact that it can be masked with other disorders such as alcohol or drug abuse, depression, panic disorder, memory loss, and phobias. Often, headaches, chest pains, and GI complaints, to name just a few, are found in veterans suffering from PTSD. A diagnosis of any of these conditions often fails to consider that the underlying cause may be post traumatic stress disorder.

Overly stressed vets try to self-medicate themselves with either alcohol or drugs in order to alleviate their symptoms. These means, however, often lead to destructive behavior or significant health problems. Supervised medical treatment is always an advisable alternative for someone suspected of having PTSD.

PTSD Treatment: - cut this section: not relevant to ptsd claims processing

Treatment for PTSD begins with the acknowledgement on the part of the veteran that he is in trouble, and something needs to be done about it. Thus, the desire for help will lead him to the structured safety of an MD’s office. Treatment under a qualified practitioner can run the gamut from psychotherapy, calming drugs, and ultimately group therapy. Often the psychiatrist will simply begin talking with the veteran about his problems, take an oral history, and proceed from there. Such drugs as Zoloft or Prozac may be used to ease the symptoms of PTSD and promote restful sleep. Various intervention therapies are also used such as cognitive-behavioral therapy, group therapy, and exposure therapy. Exposure therapy, in particular, helps the veteran relive his traumatic experience under controlled conditions because the therapist helps him work through the trauma.

Veterans Outreach Centers (Vet Centers) are a place where veterans can come to mingle with other combat survivors and receive treatment. Counselors themselves are Vietnam veterans. Even if the demons of post traumatic stress disorder are not resolved, at least there is a place, short of hospitalization, where a man can go and be with others who are suffering from the same symptoms.

For more serious cases, admittance to the structured environment of a VA Medical Center may be the only answer.

Requirements for a grant of PTSD:
So, what do you need to establish a claim for PTSD and get it approved by the VA?

Put simply, the you must have the following: 1) a current diagnosis of PTSD; (2) evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus (or link) between the current symptoms and the in-service stressor.

Let’s begin with item number 2, credible supporting evidence that the claimed in-service stressor actually occurred, because the VA uses this as a starting point for all claims. Without a stressor, your claim will go nowhere, and possibly end up in the form of a denial letter to you.

So, what is a stressor? Simply put, it is a condition, stimulus, or life event that causes or provokes a stressful response in someone. A basic example would be combat.

Stressor Verification – Combat:

Verifying the stressor for PTSD as a result of combat can involve looking at a number of sources. One of these is your DD214 which will list the necessary qualifying medal: Combat Infantryman Badge (CIB), Combat Action Ribbon, or other medal.

After looking at the DD 214 another source of information is your military 201 Claims File. This file will list duty assignments in a combat zone, and any medals or decorations received. These are considered conclusive and include the following:

· Air Force Cross
· Air Medal with "V" Device
· Army Commendation Medal with "V" Device
· Bronze Star Medal with "V" Device
· Combat Action Ribbon
· Combat Infantryman Badge
· Combat Medical Badge
· Combat Aircrew Insignia
· Distinguished Flying Cross
· Distinguished Service Cross
· Joint Service Commendation Medal with "V" Device
· Medal of Honor
· Navy Commendation Medal with "V" Device
· Navy Cross
· Purple Heart
· Silver Star

Further supporting evidence of a stressor includes plane crashes, ship sinkings, explosions, rapes or assaults, duty on a burn ward or graves registration unit, and acceptable POW status. Thus, we can readily see that the stressor does not need to be limited to a single episode, or to combat itself.

Another source of information is the Purple Heart Registry, a database maintained by the Veterans Health Administration (VHA) as part of their enrollment criteria for healthcare in a VA hospital.

Another important source is the veteran’s service medical records. The VA rating specialist will look in these records for sick-call entries or hospital reports that specifically show the name of any dispensary or hospital located in, for example, Vietnam. Unfortunately, many such entries are only date stamped above the name of the facility with no location specified. If such a record is found indicating the facility was in Vietnam, however, partial verification of the stressor is complete. Or if the record shows treatment for gunshot or shell fragment wounds, the requirement for proof of the stressor is also complete.

You will note that the Vietnam Service Medal is not among those decorations considered conclusive proof of the stressor. This is because it was awarded to anyone who served in Vietnam, the waters offshore, or the airspace above. It was also awarded for service in Thailand, Laos, or Cambodia.

VA regulations stipulate that when it is determined that a veteran engaged in combat with the enemy, his statement regarding the stressor must be accepted as conclusive. Thus, no further development on the part of the VA is required.

Stressor Verification - no combat
If you are not in receipt of one of the approved medals, the VA will send you what is called a post traumatic stress disorder development letter. This letter asks you to list specific details concerning the stressor. If the letter is returned with information such as specific incidents, dates, unit assignments, and names of witnesses, the VA will go out to the US Armed Services Center for Unit Records Research (USASCURR), formerly ESG, in an attempt to verify these statements. The VA will include a copy of your DD214, your description of the stressor or stressful incident, and copies of any pertinent military information in your 201 Claims File. USASCURR researches records of the Army, Navy, Air Force, and Coast Guard. They do not research Marine Corps records. Those records are maintained by the US Marine Corps Historical Center located in the Washington Navy Yard, Washington, DC.

USASCURR searches morning reports, unit and command histories, casualty records, etc. in an attempt to verify the stressor. Usually, they will send back copies of these reports, with pertinent parts underlined in yellow, and state the reasons why or why not verification was made. USASCURR emphasizes that military records rarely list specific experiences of individual service personnel. This makes it hard for a veteran who may be suffering from memory lapses; however, a VA claim is legalese-based, and for you to prevail you must furnish specific information. Keep in mind that this sounds like gobbledygook, but once your claim is approved, it cannot be terminated except if fraud was involved.

Another reason the VA goes out to USASCURR is because many combat histories may be readily found on the Internet. An unscrupulous veteran may access these in an attempt to prove he has a stressor. Also, since these websites have no official standing for the VA, or any other branch of the US government, their authenticity is in doubt. This does not mean that people who post to these websites are liars. To the contrary there are many heart rendering accounts of combat. So, we’re back to the legalese. Thus, for these accounts to be acceptable as proof to the VA, the stories must be verified by USASCURR or another such agency.

On the other hand, such Internet sites may prove helpful in locating witnesses to a stressful incident. Thus, your claim for post traumatic stress disorder may be strengthened by the statement of a veteran with verified combat-related experience, or any other veteran, who witnessed the stressful incident.

If the letter from USASCURR does not show that the claimed stressor is verifiable, the rating specialist will deny the claim. One incident that this writer witnessed was a veteran who had a diagnosis of post traumatic stress disorder from a VA psychiatrist. The diagnosis was based on information which the veteran gave his doctor. Unfortunately, the veteran’s military personnel file showed he had never left the continental United States. As a result, his claim was denied.

Stressor Verification – Personal Assault

For post traumatic stress disorder as a result of personal assault the rating specialist will review the service medical records and 201 file, looking for verification, either in the form of sick-call or hospital reports, or any other evidence that showed the stressful incident occurred. If no verification is found the rating specialist will send a letter to the claimant asking him/her to furnish current medical evidence showing that he/she had a stressful experience.

Examples of such requested records would include the following:

· Records from law enforcement authorities
· Records from rape crisis centers, hospitals, or physicians
· Pregnancy tests or tests for sexually transmitted diseases, and
· Statements from family members, roommates, fellow service members or clergy.

The rating specialist will take into consideration behavioral changes that may indicate the presence of a stressor. According to the VA manual these may include, but are not limited to the following:

· Visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
· Sudden requests for a change in occupational series or duty assignment without other justification
· Increased use or abuse of leave without an apparent reason, such as family obligations or family illness
· Changes in performance and performance evaluations
· Episodes of depression, panic attacks, or anxiety but no identifiable reasons for the episodes
· Increased or decreased use of prescription medications
· Increased use of over-the-counter medications
· Substance abuse such as alcohol or drugs
· Increased disregard for military or civilian authority
· Obsessive behavior such as overeating or undereating
· Unexplained economic or social behavior changes, and
· Breakup of a primary relationship.

As you can see, there is not always a clear-cut pattern of evidence showing that a personal assault occurred. Most likely, the claimant was too humiliated to report the incident to military authorities. Even if this was done, there are cases where the unit commander or other responsible person did nothing to investigate and punish the perpetrator. A lack of record keeping is not uncommon. This makes the job of the rating specialist difficult but not impossible. In such cases the rating specialist will look for a pattern indicating some type of behavioral change. For example, a serviceperson may have had an exemplary work record up to the time of the personal assault, but now is considered marginal. That gives a pretty strong clue that the assault occurred.

As stated in the previous paragraphs above there are three requirements for consideration of a claim for post traumatic stress disorder. Now that the issue of the stressor is granted, let’s look at the requirement for a (1) a current diagnosis of PTSD:

Who can make a diagnosis of post traumatic stress disorder? Usually, a licensed psychiatrist does this. VA regulations also stipulate a VA psychologist at the GS-13 level, or a private psychologist holding a PhD in psychology or a related field of study, may make such a diagnosis.

The diagnosis of PTSD can be made only if the veteran has experienced a stressful incident. The response to the stressful incident must be manifested by intense fear, horror, or helplessness. Also necessary for the diagnosis is the presence of what are called “intrusive recollections” in the form of daytime fantasies, nightmares, and flashbacks. Further criterion include the requirement of avoidance/numbing, which are tactics the veteran may use to avoid stimuli associated with the horrors of combat or some other stressful event. Such numbing and withdrawing to avoid pain makes interpersonal relationships hard to maintain.
Additional requirements include those of hyper-arousal, insomnia, irritability, and startle response. These criteria must be present for at least one month, and must be manifested in significant social or occupational problems that are related to the PTSD.

The occasion may arise where two opposite diagnoses exist. For example, one examiner states the veteran has PTSD; the other says he does not. In this case the rating specialist will send a VA examination request to a VA Medical Center asking both doctors to agree in their diagnoses. This is usually phrased on the exam request as follows: “We have diametrically opposed diagnoses regarding PTSD. The two examiners are to review the claims folder and reach a consensus. If they can not, a panel of psychiatrists should review the claims folder and reach a decision.”

(2) Credible supporting evidence that the claimed in-service stressor actually occurred.
This was discussed in the preceding paragraphs, and dealt with both combat and non-combat veterans, as well as cases of personal assault.

(3) medical evidence of a causal nexus (or link) between the current symptomatology and the claimed in-service stressor.

This is usually the most complicated part of the three requirements, and is best left to the judgment of a qualified medical professional. Suffice it to say that a diagnosis of post traumatic stress disorder must conform to DSM-IV. Also, the examiner must review the VA claims file, review all the evidence, and link the stressor to the current symptomatology.

The VA examination
If a credible stressor is found the rating specialist will schedule you for a VA examination. During the examination the examiner will ask you certain questions related to your post traumatic stress disorder claim. Based on these answers, and a review of all the evidence, he will make a nexus (or link) between the current symptomatology and the claimed in-service stressor. The DSM-IV-TR criteria for PTSD, which your examiner will use during the VA examination, are listed below:
A. The person has been exposed to a traumatic event in which both of the following have been present:
1. The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.
2. The person's response involved intense fear, helplessness, or horror. Note: in children, it may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently re-experienced in at least one of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5. Physiologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hyper-vigilance
5. Exaggerated startle response
E. Duration of the disturbance (symptoms in B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if: Acute: if duration of symptoms is less than three months
Chronic: if duration of symptoms is three months or more
Specify if: Without delay onset: onset of symptoms at least six months after the stressor

The GAF:

After a nexus (or link) between the current symptomatology and the claimed in-service stressor has been established by the VA examiner, the next step is to determine the severity of the post traumatic stress disorder. This is done with the use of a Global Assessment of Functioning (GAF).

A GAF is an indicator of your psychological, social, and occupational functioning. It is assigned by the examiner, and ranges in severity from 0 to 100. That is, the lower the GAF score, the more severe the symptoms.
If additional mental disorders are present with a veteran who has post traumatic stress disorder, the rating specialist is obligated to ask the VA or other examiner to separate these disorders from the PTSD diagnosis. The examiner will then assign one GAF for the PTSD and another for the secondary condition. This procedure can become rather sticky, but at least it makes it easy to determine exactly the degree of disability for PTSD.
Multiple GAF’s can be assigned to show the progressive seriousness of post traumatic stress disorder over a period of time. For example a veteran was assigned a GAF of 54, which equates to an evaluation of 50%. Several months later the veteran reported additional problems that equated to a 70% evaluation. His award was written to show two effective dates for the progression of the PTSD.

The presence of violence towards himself and/or others is considered an indication of a very acute manifestation of PTSD in a veteran. Accordingly, the examiner will assign a much lower GAF. If the evidence then shows that the veteran is unable to “perform substantially gainful employment” (ie, you can’t hold a job), Individual Unemployabilty may be assigned. Individual Unemployabilty benefits, it should be noted, are payable at the 100% rate. If the GAF is extremely low, say 30 or under, the rating specialist should simply rate the post traumatic stress disorder at the 100% level, thus eliminating the need for an Individual Unemployabilty determination.

After your claim for post traumatic stress disorder has been approved at say the 70% rate, and you are still working, a routine future examination will be scheduled after two years. Your award letter will probably contain the following statement:
“Since there is a likelihood of improvement, the assigned evaluation is not considered permanent and is subject to a future review examination.”

Simply put: show up at the VA exam. If you fail to show up for the examination, you will be sent what is called a predetermination letter. This letter gives you 60 days to respond showing why your benefit should not be reduced. Failure to respond means your award will be suspended, and that means your monetary benefit stops.

After your claim for post traumatic stress disorder has been approved at the 100% rate, and it appears that you will continue to remain severely disabled, educational benefits for your spouse and children may be granted. These are called Chapter 35 educational benefits.

PTSD and cardiovascular conditions
Currently, there is no acceptable link between cardiovascular conditions and post traumatic stress disorder. This comes from the VA’s own National Center for PTSD. When a doctor does make such a nexus, however, the rating specialist must consider the doctor’s training and field of expertise. Specialists always receive more credence as, for example, a cardiologist over a general practitioner. In such cases the rating specialist will go out and obtain the opinion of a psychiatrist in an attempt to balance the two opinions. Keep in mind that a diagnosis must be relevant to the particular veteran the psychiatrist is examining. Generalities about PTSD, even coming from a qualified medical practitioner, will not be accepted by the rating specialist.

If your claim for PTSD is denied, do not lose hope! First of all, read the letter the VA sent you, and look specifically at the reasons why your claim was denied. Next, send a one sentence letter to the VA stating you disagree with the decision. This protects your appeal rights; however, your letter must be sent within one year of the VA denial letter. In this letter, you can submit any additional evidence you feel is relevant to your claim, or any information the VA requested but you failed to send.

Since the VA appeals process is a precise yet often uneasy process to understand, I would strongly advise contacting a local service organization such as the DAV, American Legion, VFW, or others. A service rep will explain exactly why your claim was denied and help you process your appeal. Sometimes, it’s as simple as not sending in that one piece of information you thought was a waste of time. So, don’t lose hope.

References: M21-1MR
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