Crohn's, Biologics, am I screwing myself?

JoePlasm

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#1
Not sure if this is the best place to post first or not, but I have some questions and after reading around everyone seems so helpful and knowledgeable.

Background: Army AD with 18yrs and 2 months, jump status for last 10 years, 2 Irq, 3 Afg deployments.
DX info:
I had a posteior and anterior anal fissure while deployed to Afg, that they did surgery at BAF for after it wasn't healing. Ant fissures are 95% IBD dx, but my colo was negative at the time. Fissure recurred at school the next year. Fast forward to next deployment 2-3 yrs later, had symptoms start in deployment, sucked it up, came home diagnosed with Crohn's (this spring). I've had a recurrence of my fissure since then and now a draining fistula. Thanks to the fistula i know have to wear liners.

My GI doc, Command, and PCM are super supportive as I wanted to stay on active service and keep doing all functions of my job. There was no profiling, but proper documentation is in my ALHTA. My goal was to do 23-24 years, and everyone was willing to help me find a way to meet that goal and not just MEB me out. But now I've failed mesalamine and have been determined to be steroid resistant. Because of that GI is having to place me on Remicade and probably Imuran. Both place me in CENTCOMs non-deployable, but 40-501 doesn't actually require MEB for use of biologics. It only states does not meet the standard "if not controlled". SO my GI and PCM are basically NOT starting an MEB because they feel I haven't been given the opportunity to be "controlled" as I have not had a medication response yet, so we are effectively still in the first step of finding treatment. Since my diagnosis is less than a year old and I've never been profiled I don't have an MRDP to "force" their hand I'm told. So basically they are goign to let me stay until we find out if Remicade and Imuran get me controlled, then they will take me off Imuran and see if Im stable. If so, they plan to let me stay and just apply for CENTCOM waiver if I we ever go back there. As I said my Command is supportive and since I can do my daily job without profile and we are not pending a deployment they are happy to leave me alone as long as I keep them up to date.

So now my questions...

Am I screwing myself later by doing this? I want to finish my intended goal. But I am worried that if this all works out and I can meet my goal when it comes ready to retire I'll be found "Fit for Duty" since I'd have dealt with it for another 4-5 years. (Even though I suspect I'm only "getting away with it" because of supportive Cmd and Med staff).

How does VA deal with things that have since improved? I.e. VSARD(sp?) For fissure or fistula is 30% if you wear a pad. If my fistula resolves with the Remicade, is that still included in my rating? Same for the disease itself, Crohn's is rated under UC (which is bu**sh** by the way apple and oranges). This summer I would have been 100% as I lost 20lb was malnourished had anemia from blood loss and admitted to hosp. But if I respond well to treatment, my symptoms may be as low as the 10% mark. I don't understand if VA uses symptoms at their worse when not treated to calculate, or if they use symptoms at the time of eval ignoring that I could be on significant medications just to reach that point.

Same info for the Army PEB - do they set my disability rate at time of eval or a time of worse or "average" symptoms?

I have no intention of PCSing and will likely ask for MEB directly and Profile if I come on orders as I worry that a new command or new post would not support me staying, as well as might not be as supportive in the MEB process as my current location appears to be (even though Im not actually in the MEB process).


Sorry for super long post, but thought it would be easier to try and give you info instead of asking me to fill gaps. Let me know if I missed something in order to get some advice. Thanks for anything you have to offer.
 

chaplaincharlie

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#2
A partial answer; anal leakage is rated:
7332 Rectum and anus, impairment of sphincter control:
Complete loss of sphincter control 100
Extensive leakage and fairly frequent involuntary bowel movements 60
Occasional involuntary bowel movements, necessitating wearing of pad 30
Constant slight, or occasional moderate leakage 10
Healed or slight, without leakage 0
 

JoePlasm

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A partial answer; anal leakage is rated:
7332 Rectum and anus, impairment of sphincter control:
Complete loss of sphincter control 100
Extensive leakage and fairly frequent involuntary bowel movements 60
Occasional involuntary bowel movements, necessitating wearing of pad 30
Constant slight, or occasional moderate leakage 10
Healed or slight, without leakage 0
Much obliged - so 30% for that right now. But if it heals from the Remicade, do they still give you the rating? That's where I'm confused, i.e. is it a hx of x, or just the severity of x at time of eval?
 

gsfowler

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Your rating comes from the C&P evaluation during the MEB. For UC there is language which refers to the condition over a year (If it is severe, but not constant, with many attacks a year that cause malnutrition which then causes overall bad health that cannot be fully recovered during the periods in between attacks, it is rated 60%. If it is somewhat severe and causes some attacks a year, but less than a severe condition, it is rated 30%.)



Leakage and pads can be only proven by your own personal disclosure. You can keep a log of when you change pads.

Do you have a LOD for the injury which occurred while overseas in the combat zone? If you do not, you may want to have the investigation initiated, it could come in handy down the road to save you some taxes on your retirement.
 

Jason Perry

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#5
JoePlasm,

Welcome! I am not sure what your actual "goal" is and am not sure that anything I write will matter much as there appears to be a lot of hypotheticals/"what ifs"/and other issues that may or may not come up in your case now or down the road.

Here are some thoughts on your posts:

SO my GI and PCM are basically NOT starting an MEB because they feel I haven't been given the opportunity to be "controlled" as I have not had a medication response yet, so we are effectively still in the first step of finding treatment. Since my diagnosis is less than a year old and I've never been profiled I don't have an MRDP to "force" their hand I'm told. So basically they are goign to let me stay until we find out if Remicade and Imuran get me controlled, then they will take me off Imuran and see if Im stable. If so, they plan to let me stay and just apply for CENTCOM waiver if I we ever go back there. As I said my Command is supportive and since I can do my daily job without profile and we are not pending a deployment they are happy to leave me alone as long as I keep them up to date.
As it stands, you are not going through and have not been referred to an MEB/PEB. So, if this continues until you hit 20 years of service, you would likely have an exit/retirement physical that may well identify your condition(s) as failing retention standards. But, if that happens, you may well find yourself to fall under the "presumption of fitness rule."

Am I screwing myself later by doing this? I want to finish my intended goal. But I am worried that if this all works out and I can meet my goal when it comes ready to retire I'll be found "Fit for Duty" since I'd have dealt with it for another 4-5 years. (Even though I suspect I'm only "getting away with it" because of supportive Cmd and Med staff).
This is somewhat referenced in my above statement about the presumption of fitness rule. I am not sure what you mean by if you are "screwing yourself" or what your "intended goal" is. There are a couple of points to keep in mind. First, your situation and the facts of your case are what they are. At the same time, there are ways to seek outcomes and to document things. It seems like you are asking if one hypothetical (that you undergo PEB processing now) is better than another hypothetical (that you later undergo PEB processing) and which may be better for you. I really can't parse the answer to how many hypotheticals may play out (especially with the fact that your circumstances and conditions may change over the interim).

How does VA deal with things that have since improved? I.e. VSARD(sp?) For fissure or fistula is 30% if you wear a pad. If my fistula resolves with the Remicade, is that still included in my rating? Same for the disease itself, Crohn's is rated under UC (which is bu**sh** by the way apple and oranges). This summer I would have been 100% as I lost 20lb was malnourished had anemia from blood loss and admitted to hosp. But if I respond well to treatment, my symptoms may be as low as the 10% mark. I don't understand if VA uses symptoms at their worse when not treated to calculate, or if they use symptoms at the time of eval ignoring that I could be on significant medications just to reach that point.
The VA is supposed to rate you based on your current disabilities (based on their symptoms with treatment, at least generally). If you are better after treatment, that is how you should be rated (this is a bit simplified as there are rules about how conditions that have previously been rated should be reviewed as well as some ratings turning on the duration of the condition).



Same info for the Army PEB - do they set my disability rate at time of eval or a time of worse or "average" symptoms?
Under IDES, the Army would apply the ratings found by the VA. Though your question seems somewhat straightforward, the answer can be somewhat complicated. Overall, the ratings are determined by reference to the VASRD.

I have no intention of PCSing and will likely ask for MEB directly and Profile if I come on orders as I worry that a new command or new post would not support me staying, as well as might not be as supportive in the MEB process as my current location appears to be (even though Im not actually in the MEB process).
Not sure of the question here. It may be that a PCS or deployment would trigger an MEB/PEB.

Do you have a LOD for the injury which occurred while overseas in the combat zone? If you do not, you may want to have the investigation initiated, it could come in handy down the road to save you some taxes on your retirement.
While an LOD would be helpful, for active duty folks it is somewhat unusual to get one. You could ask for one. (Though, potentially, going down that road may end up triggering an MEB, too). You don't really need one if your incurrence of condition is well documented as to circumstances/time/place of incurrence.
 

JoePlasm

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#6
Jason,

Thanks for the break down, I guess I was more vague than I was descriptive. To clarify, my PCM thinks he can MEB right now, or with in the next 6 months when I've had the diagnosis for a year. You read it right I have not currently started an MEB.

My "intended goal" was to do 23/24 years of AD service because of where other non-Army things line up in my life at that point. So to be specific yes, I am wondering if I am hurting myself in terms of VA disability by pushing through with my goal to make 23/24 yrs, vs taking the MEB now-6 months.

My PCM tells me that if I PCS i will probably get MEB because another command and PCM likely wont give me so much leway. So his advice is just start MEB verse PCSing. Since he's giving that advice, and already told me he can start it now, I'm interpreting that to mean, he's letting me stay at the discretion of the current command, and if they change or I change he'll start my MEB. Which I then further read as I just have to tell him when I want to start, but he'll hold off for now.

I hope that makes more sense now. Thanks for explaining the VA looks at current disability, and that IDES pulls the VA's numbers.

When it comes to medical retirement your retirement % is based on the Army disability% and not your high 3, correct? Or is there some kind of funky math there?
 

JoePlasm

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#7
Gsfowler,

I've not seen LOD for AD, as the regulation says AD is under the presumption of In LOD unless gross negligence, willful misconduct, alcohol or drug use. I do have the SF-600 from the aid station and then later the surgeon in theater that referred me to Gastro. Plus the fissure and surgery are in my ALHTA from the deployment before that. I hope that's sufficient, but I don't know when it comes to the VA.
 

chaplaincharlie

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#8
Much obliged - so 30% for that right now. But if it heals from the Remicade, do they still give you the rating? That's where I'm confused, i.e. is it a hx of x, or just the severity of x at time of eval?
You are rated based on your condition at the time of the C&P. If you get completely well from all your problems you get 0. It is money to compensate you for loss in earnings capability due to illness/injury. No illness - no money.
 

JoePlasm

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You are rated based on your condition at the time of the C&P. If you get completely well from all your problems you get 0. It is money to compensate you for loss in earnings capability due to illness/injury. No illness - no money.
Tracking makes sense - the hard part is it doesn't make you well I'll have this forever. The medication just manages the symptoms, so I'll feel better but still have the disease and if the meds stop working I'm back to square one.

It's hard because other diagnosis like Psoriasis give ratings for being on "biologics" but the VASRD for GI symptoms does not. Even though the burden on the body is the same, and the permanent immune suppression will make me more prone to illness indefinitely and could very well effect my employability if I'm too sick to go in from colds and flus. (Hence the reason they give the rating for usage under other disorders.
 

chaplaincharlie

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#10
An illness can be rated in multiple ways - you can not be paid for the same illness twice BUT if one way precludes payment another way may not.
 

andimouse

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Tracking makes sense - the hard part is it doesn't make you well I'll have this forever. The medication just manages the symptoms, so I'll feel better but still have the disease and if the meds stop working I'm back to square one.

It's hard because other diagnosis like Psoriasis give ratings for being on "biologics" but the VASRD for GI symptoms does not. Even though the burden on the body is the same, and the permanent immune suppression will make me more prone to illness indefinitely and could very well effect my employability if I'm too sick to go in from colds and flus. (Hence the reason they give the rating for usage under other disorders.
I was wondering about this...I'm currently undergoing a MEB for UC and am in remission. If they would have forced a MEB before I got on Remicade, then I would have definitely gotten at least 30%, but now I'm nervous I won't even get 10%. I was thinking that I would try to fight it using the psoriasis info if they don't at least give me enough to retire. What did you end up doing?
 

andimouse

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#13
Any update?? I'm going through an MEB now and hoping that they rate remicade similar to the way they do for skin conditions or asthma.
 

JoePlasm

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Any update?? I'm going through an MEB now and hoping that they rate remicade similar to the way they do for skin conditions or asthma.
Yes a couple - I still haven't started my MED yet. My GI doesn't want to until I'm stable for 6m-1y he says he's seen to many Crohn's patients discharged and deteriorate because they weren't stable and the VA process is to slow to react for initial discharges. My unit is supportive of this as there is plenty of work for me to still do and contribute despite being non-deployable.

You can find your current disease and request "analougues" compensation/eval for things not listed in the VASRD. So you can basically say yes I have "x" but it doesnt address the unquie circumstance of my treatment that is addressed in this "y" section of the VASRD and as such I should be rated under "Y" becasue the compensation is base don the treatment not the initial disease.

However, liek I mentioned I havent gone through my process yet so I dont know how well that will go over, but thats what I am being advised.