DC 7354–THE FINE PRINT


A member sent me an email and stated that he could never qualify for 20% or more under the HCV ratings percentages even though he was very ill. He wondered how any of us ever got above that with the way it’s written. Veterans need to understand that VA writes VAspeak. They run things together and use a lot of ands and ors strategically in ratings descriptions to make some ratings “either…or” ratings and some conjunctive like A+B. So, with that said, let’s look at what is necessary, what is hidden and what it means to you in Dick and Jane speak.

DC 7354 starts with this simple phrase:

With serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection:

Nothing here of note except the innocent conclusion that you have to have an EIA or PCR test positively confirming you are infected. You might be surprised that a lot of Vets just assume they have this and file for it. On appeal 4 years later, the BVA remands you for the C&P that the VARO never afforded you and Bingo! No HCV. There are other flavors and sometimes Johnny Vet gets them confused, so VA just puts this in here to CYA.

Nonsymptomatic——————————————o%

Well, this is self-explanatory. If you were puke sick, went through IFX treatment and healed, this is where you may end up. If you somehow survived unscathed, and by that I mean you kept all your mental faculties, VA will be disinclined to pay you. I personally have never met any Vet that came out the other end of the Interferon tunnel with no side effects. VA sees this all the time and that is why we have a 0% in the code.

Intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period—————-10%

Here is the first example of either/or of which I speak. You need the first set of circumstances ( fatigue, malaise, and anorexia) intermittantly to qualify. This is one distinct set of requirements. You will need to prove that you are indeed anorexic. A doctor will diagnose you somehow and write it in your records. VA has added two notes at the bottom of DC 7354. Note 1 is a prohibition of pyramiding DC 7312 (cirrhosis) symptoms on top of DC 7354. Note 2 is VA’s definition of “incapacitating episode”. What isn’t written or elaborated on is the definition of “anorexic”. VA uses this as their default definition:

http://www.law.cornell.edu/cfr/text/38/4/112

VA will keep close tabs on you and they always weigh you when you go in so remember that. One of our enterprising  members       ( Ralph) created a “weight loss” simply by packing lead weights into his jeans and boots to VA doctor appointments at the beginning of his claim. He subsequently “lost it” over succeeding months. The base line is established over time (12 months) so you sure have plenty of that. Ralphie is a real joker. He was the first to tell me about the FD&C#2 yellow food dye and black eye shadow tricks.

The other choice is the one most Vets go for.  The 10% requirement states that you must have incapacitating episodes that will require a doctor to insert a note in your medrecs that he is advising bed rest for you due to these horrible symptoms listed. Notice the “and” at the end encompassing RUQP. While no one will have all the listed incapacitating symptoms, it is expected most will suffer a majority of them. If all you report is RUQP and get nothing from the Doc on paper about how rotten you feel, chances are you are going to stay at 10%.

The VA takes great stock in how many days you are incapacitated. Thus, if you let “oh… about 5 or 6 days a month” escape your piehole, do not be surprised when VA says “The Veteran stated he is incapacitated less than a week every month” thus he does not qualify for a 10% rating.” I have read that too many times and the member says “Well, yeah, I guess that’s what I said, but I didn’t know they were that picky.” Veterans, you haven’t seen nuthin’ yet.

 Daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period———————————-20%

Again, we see the or dividing the two sets of symptoms. Some Vets end up on prednisone to try to keep an overactive autoimmune system at bay. This “continuous medication” can also be construed as Interferon and Ribavirin because it is being taken for your illness. Any of the medications for cirrhosis like Lactulose do not qualify technically, but you are encouraged to list them all. My theory is that Morphine probably qualifies if it can be said you’re eating it for arthralgia. I had one industrious Vet who stated to his doctor that cinnamon, peanut butter, tomato sauce and garlic made him nauseous enough to throw up. The good doctor wrote this into his records with an admonition that the Vet should try to refrain from eating these items. This qualifies as a diet restriction. He wasn’t lying. If you eat them all at once, vomit happens. Here, again, the Vet is advised to push heavily about how many days he is incapacitated for the record. The magic minimum is 14 days now, but no more than 28. VA will not get anal about proving this yet. They start to require proof of time lost in the form of time cards or your supervisor’s letter stating as much later when you attempt the 40% hurtle. Another VA trick is to say that “The veteran does not mention any time lost so it is assumed he had no incapacitating episodes.” It certainly wouldn’t hurt to document this with pay stubs showing hours worked now. I say this because I sense the VA is on the brink of tightening up the purse strings on money. Congress is soon going to get ugly about how much is spent and everyone is going to suffer. The Department of Veterans Affairs swallows an incredible amount of the budget and it is increasing faster than the National Debt,  so we are in the crosshairs.

Daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period-40%

At this juncture, VA is going to start taking a long hard look at you. Hepatomegaly is the enlargement of the liver. This is something you cannot fake. The gastrodoc will have you lie down and he’ll feel the edge of your ribcage and then discern the liver below it. The more swollen it is, the larger it will feel on palpation. Notice this rating will also require minor weight loss defined as at least 10% less than your heaviest period in the last twelve months. For the mathematically challenged, 10% of 180 lbs. is 18, thus 162 lbs. constitutes what you need. After the red or you will see the incapacitating episodes criteria is increasing. 28 is now the minimum and 42 is the ceiling. As you can see, this is still an either… or ratings proposition as the prior 3 have been. Obviously some symptoms will overlap, but the important one will always be the days lost to this.

Daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly——————————————–60%

At this stage, VA is really looking under the hood. Over the course of the rising ratings above, there has been mention of weight loss, both stated and silent (anorexia). VA will spring this on you if you do not show evidence of it. Here, at 60% the requirement jumps to substantial weight loss. If you intend to go for the requirements of the first batch, your 180 lb. person will now have to weigh in 36 or more pounds less at 144.  That’s a mighty tall order to accomplish with wheel weights. I went from 165 to 118 in the hospital while VA was playing “Operation” on me. It’s grueling to say the least, but it had nothing to do with my hep. It was all Crohns disease issues and being fed through an IV for 3 months. Going for the second set of issues is simple if you can document those 42 days on paper. Paper as in medical records paper. It makes no difference if they are civilian or VA doctors. Pay stubs are advisable as well. If you are indeed suffering incapacitating episodes, it’s assumed you’re on a first name basis with the doctor and nurse by now.

This last rating is the almost insurmountable hurtle and I cannot emphasize how much VA will do to poke holes in your doctor’s assessment.

Near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain)————————————-100%

Many is the Vet who applies for 100% and is denied. The reasons vary, but the one common denominator is the language employed. The words “near-constant debilitating symptoms” must be physically written into your medrecs. Anything less will not suffice. You, Joe Vet, cannot state this is the case. Only your doctor can do this. I had one Vet state this in his request for increase and the denial stated that he had no supporting medical evidence saying that. We had the doctor write that in an addendum and he had the rating in less than two months. I cheated a little bit by just using the phrase to describe my condition to my doctor. He wrote it in verbatim and I lucked out. I had spotted it in a BVA decision and knew I needed it. I also wrote it down on the QTC form for the P&T exam.

Face it-there are only so many ways you can say this. VA is adamant that it be done exactly like this so do not try to improvise and make yours unique. If you are still working, the odds are 100% you will lose, too. Near-constant pretty much rules out working -even occasionally. One Vet’s wife wrote a supporting letter saying “It’s very difficult for my husband. He can barely work now.” Bad idea. He lost. VA hates to hand out the big ticket ratings. They have a mentality that you need to be at death’s door to get 40%. They also assume you are dumb as a post and pray you won’t visit web sites like this one.

Getting to the 100% rating is an arduous process and requires you to be very sick. You will probably need an ugly liver biopsy and some assessment that you won’t be voting in the 2024 elections. High AST/ALTs (in the 100-200s) are very helpful. Having a doctor who commiserates with your plight is a prerequisite. You sometimes have to go back to him several times to get the letter right because Dr. Bozo wants to say ” The patient is very ill and has episodes that require him to occasionally seek bed rest several hours a day.” It sounds good, but it won’t fly with Uncle Victor. Hopefully this will help you and save you months or years of experimenting with the right phrase to win.

And here, ladies and gentlemen, is a classic example of what happens when you don’t have all the ingredients for the recipe:

http://www.va.gov/vetapp11/Files3/1126591.txt

About asknod

VA claims blogger
This entry was posted in General Messages, HCV Health, Introduction-Read these first, Tips and Tricks, Uncategorized and tagged , , , , . Bookmark the permalink.

2 Responses to DC 7354–THE FINE PRINT

  1. asknod says:

    The weight issue you mention is endemic with ascites. This is usually comprehended by the tenets of Diagnostic Code 7312 which deals with cirrhosis. VA makes a habit of confusing the two-perhaps on purpose-to delay or deny the inevitable. I honestly had never thought of augmenting my symptoms because they were so numerous. Some who have encountered the VA medical system discovered they were in “amazingly good health” even though their Liver Function Tests told a different story. VA examiners are not noted for their perceptive abilities. Imagine a mathematical construct that involves 5 numbers. 0,1, 2, 3, 4,10,11,12,13,14, 20… If you do not know your system is missing component parts, you work with what you have. VA has always worked in a closed system that does not provide for inductive logic-just deductive. If something is missing from the evidence pile, then it simply doesn’t exist. No search is necessary because it will be fruitless. And if the evidence is incomplete, it is not the fault of the VA. The claimant is responsible for providing that which will prove his case. The mere fact that VA, and by extension the government, is in charge of said records, is immaterial. It is still the claimant’s responsibility. A system such as this vests all the power in the VA with none accruing to the Vet. Strange, isn’t it? A system set up to serve America’s Veterans and specifically designed so that every benefit coming to a Vet is realized begins by erecting a barrier so tall that few can climb over. Nevertheless, that is the hand we are dealt. That some might choose to apply a little makeup to enhance their chances seems perfectly apropos. One note of caution-always put you weights on your person and not in your overcoat.

  2. Dottie says:

    The weight loss thing always amazed me. When you are swollen from fluid you weigh more. My husband was losing muscle mass but still weighed in at 236 up until transplant. No shoulders, just abdomen. After the swelling went down from surgery he weighed 211. He now weighs 207 at 6 feet tall and they still call him obese:) I think the man had the right idea with the weights

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