Pediatrician as VA examiner

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dwbell99

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Where can I find supporting evidence that will discredit the medical opinion for a VA Examiner whose medical clinical specialty is Pediatric Emergency Medicine is not qualified to rate for DEGENERATIVE DISC DISEASE, LUMBAR SPINE ?
 

Hawaii5-0

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Where can I find supporting evidence that will discredit the medical opinion for a VA Examiner whose medical clinical specialty is Pediatric Emergency Medicine is not qualified to rate for DEGENERATIVE DISC DISEASE, LUMBAR SPINE ?

I don't know your examiners exact board certifications (you can search ABIM & AEM boards) but most Peds EM fellowships require prior training in a three-year residency in either General Pediatrics (Peds) or Emergency Medicine (EM). So, the providers background should be sufficient to examine that common aging disease process.

But hey...if you really don't like how your exam went down, read the following.

Take the time to read this VLB blog on this very topic
"... under the “presumption of regularity”, VA is presumed to have chosen the best medical practitioner for the job. "

You CAN OBJECT to the provider and he lists how to do this in 1-5 of this blog post.



For psych exams for example, " Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists.."

A TBI example that just popped up in the news is below.

"VA just funded a research study now being used to support lowering credentialing requirements for examiners diagnosing traumatic brain injury (TBI).
The agency funded a research study performed by the organization formerly called NIH, now called National Academies of Sciences, Engineering, and Medicine (NASEM), to evaluate diagnostic requirements for TBI.
The congressionally chartered research organization evaluated whether the agency should still require that only one of four specialties diagnose the condition – a neurologist, neurosurgeon, physiatrist, or psychiatrist. The 200 plus page report argues that training and experience, “not necessarily the specialty,” is what makes a clinician capable of accurately diagnosing TBI."

TBI study for VA exams
 

gsfowler

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Where can I find supporting evidence that will discredit the medical opinion for a VA Examiner whose medical clinical specialty is Pediatric Emergency Medicine is not qualified to rate for DEGENERATIVE DISC DISEASE, LUMBAR SPINE ?

Why would you think a board certified physician would not be qualified to do the examination for your Thoracolumbar Spine?

Here is the examination form, any physician, nurse practitioner or physicians assistant can conduct the examination.


FWIW the physicians do not rate you, they just conduct the exam per the SOP and report it on the prescribed form. If you are unhappy with the exam, request another one. You do not have to accept an exam conducted by a VA contractor, you have the right to be examined by a VA employee if you wish.
 

dwbell99

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I don't know your examiners exact board certifications (you can search ABIM & AEM boards) but most Peds EM fellowships require prior training in a three-year residency in either General Pediatrics (Peds) or Emergency Medicine (EM). So, the providers background should be sufficient to examine that common aging disease process.

But hey...if you really don't like how your exam went down, read the following.

Take the time to read this VLB blog on this very topic
"... under the “presumption of regularity”, VA is presumed to have chosen the best medical practitioner for the job. "

You CAN OBJECT to the provider and he lists how to do this in 1-5 of this blog post.



For psych exams for example, " Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists.."

A TBI example that just popped up in the news is below.

"VA just funded a research study now being used to support lowering credentialing requirements for examiners diagnosing traumatic brain injury (TBI).
The agency funded a research study performed by the organization formerly called NIH, now called National Academies of Sciences, Engineering, and Medicine (NASEM), to evaluate diagnostic requirements for TBI.
The congressionally chartered research organization evaluated whether the agency should still require that only one of four specialties diagnose the condition – a neurologist, neurosurgeon, physiatrist, or psychiatrist. The 200 plus page report argues that training and experience, “not necessarily the specialty,” is what makes a clinician capable of accurately diagnosing TBI."

TBI study for VA exams
Thanks for the advice
 

dwbell99

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Why would you think a board certified physician would not be qualified to do the examination for your Thoracolumbar Spine?

Here is the examination form, any physician, nurse practitioner or physicians assistant can conduct the examination.


FWIW the physicians do not rate you, they just conduct the exam per the SOP and report it on the prescribed form. If you are unhappy with the exam, request another one. You do not have to accept an exam conducted by a VA contractor, you have the right to be examined by a VA employee if you wish.
Physician's medical opinions can be the based for the rater's determination.

this is my contention:
VA examiner's medical opinion is of little to no probative value as VA Examiner's medical clinical specialty is Pediatric Emergency Medicine. Normally specialists who treat back pain are either specialty care physicians and Pain Management or Therapists. Pediatrists are typically limited to only seeing children in their practice, so they have a lot of experience in recognizing and treating childhood illnesses.
 

dwbell99

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PEB Forum Veteran
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Why would you think a board certified physician would not be qualified to do the examination for your Thoracolumbar Spine?

Here is the examination form, any physician, nurse practitioner or physicians assistant can conduct the examination.


FWIW the physicians do not rate you, they just conduct the exam per the SOP and report it on the prescribed form. If you are unhappy with the exam, request another one. You do not have to accept an exam conducted by a VA contractor, you have the right to be examined by a VA employee if you wish.
Because a Pediatrician does not usually have much experience with a Thoracolumbar Spine. Also, conducting an exam using a DBQ according to SOP is not a realistic standard.
 

gsfowler

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Because a Pediatrician does not usually have much experience with a Thoracolumbar Spine. Also, conducting an exam using a DBQ according to SOP is not a realistic standard.
That is an assumption on your part. Fallacy of logic, faulty generalization.

ANY physician, PA or NP is capable of conducting a physical exam. Contractors that work for the VA are given specialized training on how the VA exam is conducted.

There are only five companies nationwide who have VA contracts; Vet Fed, QTC, VEC, Logistics Health and Medical Support Los Angeles.

When they hire physicians, they (in concert with the VA) train the physician, NP or PA on how to conduct a VA examination.
 

oddpedestrian

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Post the exam here and redact identifying information if you feel it was written poorly remember the the RSVR is asking for the doctors OPINION on your back and whether or not its related to service as well as its severity not whether or not you agree with it. DDD is not a complicated medical issue that requires a specific specialty to render an opinion on. Is this for service connection or for an increase?

I was rated for back then reduced off a bogus exam appealed lost appealed again lost took it to the BVA the judge threw out the exam that led to the reduction and restored my rating I never submitted any additional evidence that's how bogus the exam was but each case is different.
 
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dwbell99

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1. This is for secondary service connection to service connected ankle.

2. Below is the Back DBQ performed by VA

SECTION I – DIAGNOSIS

1A. Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition?
[X] Yes

1B. If yes, provide only diagnoses that pertain to the thoracolumbar spine (back) conditions:
[X} Degenerative arthritis of the spine / ICD Code: M47 / Date of diagnosis: 2016
[X] Spinal fusion / ICD Code: M43.26 / Date of Diagnosis: 5/11/16; 1/19/18
[X] Spinal stenosis/ ICD Code: M48.06 / Date of Diagnosis: 2016

1C. If there are additional diagnoses pertaining to thoracolumbar spine (back) conditions, list using above format:
Degenerative Disc Disease, L5-S1 / M51.3 / 2016
Radiculopathy, bilateral lower extremity / M54 / 2018


SECTION II – MEDICAL HISTORY
2A. Describe the history of the Veteran's thoracolumbar spine (back) Condition (brief summary).

Date of Onset: 2012

Details of onset: Veteran states that he began to have back pain around 2012. No distinct trauma. Veteran states that he has had an uneven gait for years secondary to left ankle condition.

Course of the condition since onset (Has the condition progressed? Stayed the same?)
Back pain worsened over time. Veteran found to have Degenerative Joint Disease (DJD) / Degenerative Disc Disease (DDD) of the spine with subsequent spinal fusion surgery x2.

Current symptoms (or state if the condition has resolved):
Back pain radiating down bilateral lower extremities with numbness and tingling of lower extremities.

Any treatment, medications or surgery?
Fusion L3-L4, L4-5 5/11/2016
Fusion L5-S1 1/19/2018
Norco, Gabapentin, Muscle Relaxers
Physical Therapy, Back Brace

Any previous x-rays/labs/testing (if not available for review, simply state so)?
Interval L3-L5 lumbar spinal fusion as above. Examination is slightly limited by metallic artifact-and-lack of contrast.
Progressive disc protrusion of L5-S1 with mass effect upon the S1 nerve root.
Progressive spondylosis at L2-L3 with moderate central spinal canal stenosis.

2B. Does the veteran report flare-ups of the thoracolumbar spine (back)?
[X] Yes
If yes, document the veteran's description of functional loss or functional impairment in his or her own words:
Back pain flares up with prolonged sitting, standing and walking and with bending and lifting.

2C. Does the Veteran report having any functional loss or functional impairment in his or her own words:
Difficulty with long drives, unable to bend or lift. No longer able to run.

SECTION III - INITIAL RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS

3A. Initial ROM Measurements
[X] Abnormal or outside normal range
Forward Flexion (0-90): 0 to 50 degrees
Extension (0-30): 0 to 15 degrees
Right Lateral Flexion (0-30): 0 to 15 degrees
Left Lateral Flexion (0-30): 0 to 15 degrees
Right Lateral Rotation (0-30): 0 to 15 degrees
Left Lateral Rotation (0-30): 0 to 15 degrees

If abnormal, does the range of motion itself contribute to a functional loss?
[X] Yes, Difficulty bending to lift or reach down or forward.

Description of Pain:
[X] Pain noted on examination and caused functional loss.

Which ROM exhibited pain?
[X] Forward Flexion
[X] Extension
[X] Right Lateral Flexion
[X] Left Lateral Flexion
[X] Right Lateral Rotation
[X] Left Lateral Rotation

Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine (back)?
[X] Yes
Location: L1-S1
Severity: mild to moderate
Relationship(s): 10 days post-operative L5-S1 spinal fusion

Is there evidence of pain with weight bearing?
[X] Yes

3B. Observed repetitive use

Is the Veteran able to perform repetitive-use testing with at least three repetitions?
[X] Yes

Is there additional loss of function or range of motion after three repetitons?
[X} Yes

If yes, report ROM after a minimum of 3 repetitions.
Forward Flexion (0-90): 0 to 45 degrees
Extension (0-30): 0 to 10 degrees
Right Lateral Flexion (0-30): 0 to 15 degrees
Left Lateral Flexion (0-30): 0 to 15 degrees
Right Lateral Rotation (0-30): 0 to 10 degrees
Left Lateral Rotation (0-30): 0 to 10 degrees

Select all factors that cause this functional loss:
[X] Pain

3C. Repeated use over time

Is the Veteran being examined immediately after repetitive use over time?
[X]No, if Not
[X] The examination is medically consistent with
the Veteran's statements describing functional loss with repetiive use over time.

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?
[Yes]

Select all factors that cause this functional loss:
[X] Pain

Are you able to describe in terms of Range of Motion?
[X] No, Inable to speculate as the veteran is 10 days post-operative L5-S1 spinal fusion

3D. Flare Ups

Is the examination being conducted during a flare up?
[X] No, The examination is medically consistent with the Veteran's statements describing functional loss during flare up.

Does pain, weakness, fatigability or incoordintion significantly limit functional ability with flare ups?
[X] Yes

Select all factors that cause this functional loss:
[X] Pain

Are you able to describe in terms of Range of Motion?
[X] No, Unable to speculate as the veteran is 10 days post-operative L5-S1 spinal fusion

3E. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spind (back)?
[X] Yes

Muscle Spasm:
[X] Resulting in abnormal gait or abnormal spine contour
Veteran stands in slightly flexed position to relieve pain and spasm

-------------------------------------
** etiology: the cause, set of causes, or manner of causation of a disease or condition.
-------------------------------------

3F. Additional factors contributing to disability
[X] Disturbance of locomotion
[X] Interference with sitting
[X] Interference with standing

Please describe additional contributing factors of disability:
Pain limits the amount of time that the Veteran can comfortably tolerate sitting, standing, or walking

SECTION IV – MUSCLE STRENGTH TESTING

SECTION V – REFLEX EXAM

SECTION VI – SENSORY EXAM

SECTION VII – STRAIGHT LEG RAISING TEST

SECTION VIII – RADICULOPATHY

Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
[X] Yes, If yes
8A. Indicate symptoms location and severity:
Intermittent pain (usually dull)
Right lower extremity: [X] Mild
Left lower extremity: [X] Mild

Paresthesias and/or dysesthesias
Right lower extremity: [X] Mild
Left lower extremity: [X] Mild

8C. Indicate nerve roots involved:
[X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve):
If checked indicate which side is affected: [X] Both

8D. Indicate severity of radiculopathy and side affected:
Right: [X] Mild
Left: [X] Mild

SECTION IX – ANKLYLOSIS

9. Is there ankylosis of the spine?
[X] No

-------------------------------------------------------
??? Should have been [X] Yes based on Citation Nr: 0304153 which shows that disability entitlement for surgical fusion from L2 to S1 with limitation of motion and pain, including on use, productive of functional impairment comparable to complete bony fixation (ankylosis) of the lumbar spine.

** ankylosis: abnormal stiffening and immobility of a joint due to fusion of the bones.
-------------------------------------------------------

SECTION X – OTHER NEUROLOGIC ABNORMALITIES

SECTION XI – INTERVERTEBRAL DISC SYNDROME (IVDS) AND EPISODES REQUIRING BED REST

SECTION XII – ASSISTIVE DEVICES

12a. Does the Veteran use any assistive devices as a normal mode of locomotion, although ocassional locomotion by other methods may be possible:
[X] Yes

If yes, identify assistive devices used (check all that apply and indicate frequency):
[X] Brace / Frequency of Use: [] Constant

12B. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:
Back Support – status post lumbar fusion

SECTION XIII – REMAINING EFFECIVE FUNCTION OF THE EXTREMITIES

SECTION XIV – OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS

14B. Does the Veteran have any scars?
[X] Yes,
Location: Lumbar Spine
Length is 21 cm x width 1 cm

SECTION XV – DIAGNOSTIC TESTING

15A. Have imaging studies of the thoracolumbar spine been performed and are the results available?
[X] Yes
If yes, is arthritis documented?
[X] Yes

15C. Are there any other significant diagnostic test findings or results?
[X] Yes, If yes, provide type of test or procedure, date and results (brief summary):
5/13/2017 - Impressions:
Interval L3-L5 lumbar spinal fusion as above. Examination is slightly limited by metallic artifact-and lack of contrast.

Progressive disc protrusion at L5-S1 nwith mass effect upon the S1 nerve root.

Progressive spondylosis at L2-3 with now moderate central spinal canal stenosis.

SECTION XVI – FUNCTIONAL IMPACT

Does the Veteran's thoracolumbar spine (back) condition impact his or her ability to work?
[X] Yes

If yes, describe the impact of each of the Veteran's thoracolumbar spine (back) conditions, providing one or more examples:
Difficulty with prolonged sitting, standing or walking and with bending and lifting.

SECTION XVII - REMARKS
17A. Is there objective evidence of pain when the back is used in non-weight bearing?
[X] Yes
 

oddpedestrian

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I thought you said your doctors would write these opinions for you in another thread?


Your claims are chaotic you are fighting for TDIU when you don't even come close to the percentage requirement to receive it you keep stating "well when I win this and this claim my tdiu will be approved" but you haven't won and now you have a negative opinion from the c&p examiner I told you from the beginning this was a weak claim weak claims need lots of evidence to just meet the 38 CFR 3.102 standard for a possible grant.

That's the only path to victory here.
 

chaplaincharlie

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Any provider can make an error, just as anyone in the VA can in determining the correct rating. This is exactly why there is an appeal process. AT the appropriate time use the process, it is called a VARR.
 

RonG

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Questions have been addressed. Thread closed.

Ron
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