BVA–IN SEARCH OF NEGATIVE EVIDENCE

downloadThis is a great decision with enormous parameters. It illustrates many things that are judicially useful. To begin with, it is a jetgun-based claim and, as such, is of immense interest to the Veteran population who served between 1962 and 1998. It is more than that, though. It is primer for VA claimants’ rainmakers to look at to see the pitfalls of the VA claims process. Here, the VA set out to deny Johnny Vet using a contracted VA-hired psychiatrist as the gunman. Without being too verbose, allow me to say it backfired. Read on.

From the Fort Fumble VARO 

In Denver, Colorado

As we know, you can ascertain many things from a BVA decision. Let’s analyze some of them here. Johnbo is from Denver or at least he filed there. He filed sometime in 2005 and lost initially in December of that year. He only served from May 24, 1976 to June 18th, 1976-a mere twenty four days. I suspect this may be part of his problem. VA is loathe to grant SC for claimants who are barely out of the Ping stage of their basic training. To be short sheeted, he must have had ‘issues’ which are strangely absent.

Johnboy fought this through to 2012 where he was finally granted a videoconference BVA Board Hearing with our perennial Acting Veterans Law Judge (VLJ) A.C. Mackenzie, a staff attorney at the BVA who appears to have been in training for their big banana position for over nine years. He’s been there since 2005 and occasionally sits in as an acting VLJ. As such, he strives to get these decisions anally correct even if it causes friction with his boss, Laura “SS” Eskinazi.

One thing VA is prohibited from doing is purposefully going afield and looking up nasty, negative evidence that can be used to denigrate your good name, eviscerate your credibility and utilized to deny you. It could be the Johnster has (or had) a nasty habit of ingesting illicit drugs. Regardless, if you set out to prove this, you (the VA) must be without sin. You are limited to evidence accumulated legitimately at, say, the VAMC from existing records. If Johnny got diarrhea of the mouth at one time or another and admitted to clinicians that he single-handedly tried to consume Burma’s entire 1985 production of their most famous export (opium), that would certainly be admissible in an ex parte proceeding. If he went further and illuminated all that this became a life calling as early as 18, all well and fine. It would not be permissible to fetch an old 1998 Psychiatrist’s report that stated he had this nasty habit since 18 and entered service with it if-a big if- it had been fenced off as being an illegitimate fishing expedition. Many of you are naive and do not subscribe to the idea of VA as an adversary. It is one of the most oft-employed tactics used in your denials. All too frequently, it is subtle like impugning your credibility. Sometimes it manifests as outright lies and accusations to buttress the denial. If you have not yet encountered it, you will some day.

Even before HIPPA rules became the law of the land, it was unfashionable to be sharing a patient’s information behind his back without his permission. Fortunately for Johnny, he had an excellent rapport with his ex-wife attorney. She, in turn, went to bat all the way up to the Fed. Circus and squelched a nasty report from “Doctor G.” effectively forbidding its use as negative evidence in the claim.

Prior to this, a VA examiner with the vapors who hadn’t been adequately briefed on VA’s policy on jetgun claims, had inadvertently concurred with him that his HCV was indubitably due to jetguns. This creates a bow wave in front of your claim and causes all manner of confusion. Said VA examiner had to be taken aside and given “the briefing” and a new addendum had to be added to the record “correcting” the old nexus assessment. Oddly, virtually all VA-requested addendums come back  against Veterans. Johnny’s was no different.

Note also that the initial denial was in December 2006. Further note that they played ping pong with him all the way to 2009 and accused him of being a drug dealer.

Following a review of the claims file, to include a February 2009 pain management note by Dr. R with comment on issue with drug abuse resulting in financial gain…

 

In 2012, they finally gave him a real C&P exam. This is where he obtained the first (and only) positive nexus. It is also what provoked the Board to start rummaging around in his files for something-anything- to destroy the recent, positive nexus. Being ruthless, it wasn’t long before they began resorting to illegally garnering medical information on which to predicate the denial.

Johnbo’s ex-wife stepped in and pointed out this was illegal in the lower forty eight states which caused the evidence to be redacted. That, quite simply, is how he won. The default setting in these cases is unique. Evidence is what ultimately must decide a claim. If you remove the negative facts obtained illegitimately, you are left with little to convict with. Witness O.J. Simpson’s gloves. He might have been guilty too but you have to arrive there with legitimately acquired evidence- not hearsay and innuendo.

Make no mistake about it. Where there’s smoke there’s fire. I strongly suspect that based on the Johnmeister’s short sojourn of twenty four days in boot camp that some negative evidence was uncovered preventing him from ‘Being all he could be’. Perhaps he had ‘negative life events’ that precluded serving. Who knows? This evidence was never presented from his SMRs so it’s a moot point. VA obviously thought they had this in the bag based on Dr. G’s damning recital and any further development was superfluous. It’s fairly obvious he and the ex went to great lengths judicially to have Doctor G.’s breach of medical records decorum quashed and expunged from the record. That may be what ensued during the claims hiatus from 2006 to 2012.

In May 2013, the Veteran submitted additional evidence in support of his claim, to include a statement from SMB an August 2006 federal court order that sealed the October 1998 report of psychological evaluation authored by Dr. G with notation of history of opioid drug abuse dating since the Veteran was 18. SMB is the Veteran’s ex-wife and private attorney who represented him in past VA and non VA matters. Of relevance in this case is that she represented the Veteran during federal and civil litigation against Dr. G. The federal litigation pertained to whether Dr. G violated the Veteran’s privacy when he disseminated his October 1998 report of psychiatric evaluation to the Veteran’s treatment providers and agencies from which he was seeking assistance without authorization of the Veteran and Dr. G’s claimed immunity as a government contractor. The civil litigation against Dr. G pertained to alleged defamatory and libelous statements and conclusions made by Dr. G in his October 1998 report, to include allegedly false statements and conclusions pertaining to the Veteran’s alleged history of opioid abuse since age 18. The accompanying August 2006 federal court order sealed all records referring to, derived from, or pertaining to Dr. G’s October 1998 report of psychological evaluation and prohibited dissemination of it.

chieu hoiOn its face, this appears to be using a machine gun to kill a mouse. Getting a Federal Court order to seal records in a VA claim is overkill unless you stand to make a short ton of money. In retrospect, I’m glad to see this even if JohnnyVet is a raging junkie. The VA has no business developing negative evidence, or worse, introducing it when it has been sealed. It just illustrates the belief (mine) that VA will stop at nothing to deny claims. They are renowned for their judicial antics and when called to task, shrug their shoulders and Chieu Hoi.  A week later, they begin anew where they left off as if the teaching moment never transpired.

Add this to your list of tips and tricks to review after a denial. Criminal Background Investigations (CBIs) can be had for a song and a dance. You can subscribe to an agency who performs these for as little as $10.00 a year. VA probably gets a fleet rate with 57 VAROs. Considering VA denies 85% of our claims, it can be assumed they assiduously pursue the most difficult with any means necessary to obtain the desired end.

And lastly, the “what if”? When faced with this brand of tarring and feathering, I am the type who would squander time and energy developing a case against a VA examiner. What would prevent Veterans from hiring a private eye to collect negative info on a VA employee? Why not do a CBI on one? If you uncovered a domestic violence offense in their records, could that not be said to impair impartiality?

downloadOh what a tangled web we weave
When first we practice to deceive.
 – Sir Walter Scott (Marmion, 1808)

Posted in BvA HCV decisions, Tips and Tricks | Tagged , , , , , , , , , , , , , , , , , , | Leave a comment

MORE FACEPLACE

558839_555848511126176_856374268_nA veritable avalanche of Face implants arrived after the last post. I share with you herewith:



 

 

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I had a desert tortoise I brought up from California when I moved here in April 1974. His name was Phillip Morris after my smokes or simply Morris. He lived under the sofa and hibernated there in winter. He was fond of bare toes nestled in open-toed sandals. I used to wait until he was on the verge of chomping down to tell my friends. I’d be put in jail by the Sierra Club in 2014 for tampering with the desert now.

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VA–BAD BOYS-BAD BOYS

downloadWe always knew there was a mechanism for this from the day the VA Kiddy Kops took down John Bisig, a 280% disabled Vet in Houston back in 2011. Keeping in mind that John was decompensated, well-educated, verbally gifted and opinionated, it stood to reason he would run afoul of VA’s jack-booted thugs eventually. He did. He survived with minor lacerations from the handcuffs and frog march to the holding cell.

VA never has brooked much discontent or loud voices in their buildings but no one asks the obvious question. Why is it you do not hear these raised voices in normal hospitals? Why is it commonplace at the VAMCs? On Ward 3 East, it was not uncommon to hear Vets bellowing for a nurse for 30 minutes at 2300 hours. That was during my sojourn there for a year in 2009. Too much hullabaloo was grounds for a trip to the sixth floor and the Psyche ward where you needed a key to leave.

A warm thank you to JM for spotting this and sending it in. Knowledge is power when dealing with Victor Alpha.

Posted in All about Veterans, Food for thought, vA news, VA statistics | Tagged , , , , , , , , , , , , | 2 Comments

VA study: HCV can cause non-Hodgkin lymphoma. Are veterans the last to know?

Anatomy_of_the_Lymphatic_System

“2201 Anatomy of the Lymphatic System” by OpenStax College – Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.. Licensed under CC BY 3.0 via Wikimedia Commons – https://commons.wikimedia.org/wiki/File:2201_Anatomy_of_the_Lymphatic_System.jpg#/media/File:2201_Anatomy_of_the_Lymphatic_System.jpg

We know that HCV can lead to liver cancer, but blood cancers too? Yes. HCV isn’t just swishing around in a body’s blood stream happily replicating in liver cells.  HCV makes changes to other bodily systems and structures in some “small but significant” number of unlucky victims in the form of non-Hodgkin lymphomas (NHL).

The VA has been quietly digesting this information for seven years and at a time when they believed that only 5% of veterans were stricken with HCV: Risk of non-Hodgkin lymphoma and lymphoproliferative precursor diseases in US veterans with hepatitis C virus.  (JAMA :2007 May 9; 297(18):2010-7) Full report in pdf here.  PubMed Link to Abstract here; A summary here.

CONCLUSIONS: Hepatitis C virus infection confers a 20% to 30% increased risk of non-Hodgkin lymphoma overall, and a 3-fold higher risk of Waldenström macroglobulinemia, a low-grade lymphoma. Risks were also increased for cryoglobulinemia. These results support an etiological role for HCV in causing lymphoproliferation and causing non-Hodgkin lymphoma.

Chart from Cancer.gov (Click image) has been moved to the wayback machine:  (LINK) HCV is carcinogenic for HCC and non-Hodgkin lymphoma.

virus lymSo what is non-Hodgkin lymphoma? Butler VA: “.. a group of cancers that affect the lymph glands and other lymphatic tissue.”

The risk factor for getting NHL are increased for my husband because he not only was exposed to AO, but he lived at Camp Lejeune and was infected with HCV in service (since he had/has no other risk factors).

The University of Utah has a healthcare online library that spells out some of the key risk factors such as being 60 years old, male, and having hepititis C as well as survival rates etc..Many medical professional websites (ex. Mayo) with NHL information are silent on HCV as a transformative agent.

Note:  This study did not find an association between HCV and thyroid cancers but it is not current.  Also, the prevalence of HCV is a shocking 18.4% for veterans born in 1954 so this issue needs to be revisited.

Posted in Guest authors, HCV Health, HCV Risks (documented), Medical News | Tagged , , , , , , , , , , , , , , , , , , | Leave a comment

CAVC–MOYE V. SHINSEKI-THE PRESUMPTION ACCORDING TO ST. BAGBY

thumb_d10d7a64-04ab-4462-9561-19cb885ef6d9My eye, as most know, is drawn to Court reversals as they offer the most cutting -edge jurisprudence and the best read for the money. Leroy Macklem is a recent, classic example of this and Mr. Moye’s win will be back to the same era (the 70’s). The two cases bear little resemblance other than they share the Clear and Unmistakable Error (CUE) theorem. Leroy’s was pure hot air and probably will hold the BVA record as the biggest brain fart in five decades on the part of the RVSR who stepped on his necktie. Mr. Moye’s Motion to Revise, however revolves around our old friend Mr. Jesse E. Bagby.

The Presumption of Everything Worth being Presumed Upon at the VA reigns supreme. So much so that it becomes an albatross around Will E. Gunn’s neck on occasion. downloadHe will have to worry no more. I noticed he wisely connected his chin strap on his brain bucket and hooked into the Static Line this morning. Gunn was gone with the Green Light along with the principal assistant Under Secretary for Veterans Health (an oxymoron). I’m sure there will be a rush to the exits in good time. These far thinkers simply had the foresight to avoid the inevitable tar and feather treatment visible on the horizon.

Mr. Richard L. Moye got a surprising decision from, of all judges, Bruce “Almighty” Kasold. We would have been quailing in our shoes had we been at his mercy. Some have recalled his first word was “affirmed” before he even learned how to say Moma. A reversal would be the only reasonable outcome of this in any normal Courtroom, but it is remarkable for him so I merely mention it here.

Moy reversal

Let’s review this in DickandJane Vetspeak. We variously hear of the presumption of regularity in the mail- i.e. if we mailed it, it’s presumed you got it because the USPS is extremely trustworthy. Mail carriers are not prone to rent storage lockers and stash their letters there. We are assuaged that administrative procedures of VA are always followed to a T such as scheduling appointments (Presumption of Validity). Since VAMCs are infallible, the presumption that every medical procedure ever performed anywhere, anytime by VA doctors was correct and free of malpractice is in force. We are consoled by the Presumption of “We followed the law” that everything was above board back in 1979 when Mr. Moye filed his first claim for flat feet and that all the evidence was considered in spite of the fact that the VA and BVA were somehow exempt from having to actually get anally specific on why you were denied. I’m not kidding you. Until about 1990, the VA was sending out SOCs that simply said “Sorry we can’t grant your request. Thank you for your Service.”

The Dickmeister wins this for one reason. He, the Veteran, gets his one ace card to deploy which is the Presumption of Soundness. When you enter the service, you get the hairy eyeball. Every mole is annotated. Even if you say you had “foot problems” before service, if they accept you without declaring it medically on the SF 88, it is because they do not see it. Once in service, if something goes haywire, as here, absent a noting of the infirmity or defect at entry, you get the “whole enchilada” presumption.  Rebutting that is usually a tall order. Well, not in Jesse’s case so much. All they did was call up his old doctor and ask him if Jess had any ulcers before he joined up. Busted! In Mr. Moye’s case, they resorted to presuming that the collection of evidence and the rationale for the decisions was the same over in the military.

Richard got the same initial presumption as Jesse at entry but then developed his mega-pes planus problems after he’d been in a while. Only then did they do the military Medical Evaluation Board (MEB) on him and sent him packing. Herein lies the problem. The BVA Veterans Law Judge was “judicially challenged” because he foolishly relied on the MEB and Richard’s own tacit admission of unspecified “foot problems” before service to constitute sufficient evidence to rebut the Presumption of Soundness. In order to rebut something, the legal standard requires that you prove it was clearly and unmistakably erroneous. Once we go down that road, a whole new set of rules applies-even to VA. Our old friend Mr. Russell immediately becomes paramount. All things CUE have CUE rules. Mr. Moye set out to prove CUE and did because VA made that false presumption that they had rebutted his soundness. Always remember, all these claims hinge on the evidence of record at the time of the decision. That much is usually still in the C-file unless you filed in Dayton or Detroit where the thin air causes files to evaporate.

Here’s a copy of Mr. Russell’s and Miz Collin’s dust up with the Court back in 1992. It became the CUE Bible with a few additions later (Fugo, Caffrey etc.)

russell_90-396

Fugo

Caffrey

Russell enunciated the pure concept that there can only be one correct decision. You can’t have it both ways. Either you’re a little bit pregnant or you’re not at all. When you aspire to go back and re-argue it, you cannot disagree with how the evidence was evaluated. You can, however, attack the law if they do not follow it or misinterpret it. Once you prove they broke or ignored the law, you have to prove it manifestly changed the outcome. I don’t think that matter is in dispute here.

The Board’s analysis is faulty. Certainly, the 1979 RO is presumed to have considered the evidence, Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007), and, although not stated by the Board, it is presumed that the RO applied the law correctly, Pierce v. Principi, 240 F.3d 1340, 1355 (Fed. Cir. 2001) (“Final RO decisions are entitled to a presumption of validity.”); see also Natali v. Principi, 375 F.3d 1375, 1380 (Fed. Cir. 2004) (1945 RO’s failure to cite to presumption of soundness and aggravation does not mean that those statutes were not correctly applied). But presumptions are rebuttable, and the law in 1979 (as well as today) required evidence of pre-existence and no aggravation to rise to the level of “clear and unmistakable” in order to overcome the presumption of soundness that attaches to disabilities that manifested in service and were not noted upon entry into service. See Vanerson v. West, 12 Vet.App. 254, 261 (1999) (“[T]he standard of proof for rebutting the presumption of soundness is . . . evidence that is clear and unmistakable, i.e., undebatable.”); see also Waltzer v. Nicholson, 447 F.3d 1378, 1380 (Fed. Cir. 2006) (“Our precedent is clear that whether the evidence regarding [the veteran’s]  preexisting condition rises to the level of clear and unmistakable evidence is simply the application of the facts to the legal standard established by section 1111.”  Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004) (“[A] question as to the legal sufficiency of the evidence is a question of law.”); Gilbert v. Shinseki, 26 Vet.App. 48, 52 (2012) (“The presumption of soundness serves as a shield against any assertion by the Secretary that a veteran’s in-service disability that was not noted upon entry to service preexisted service.”).

Will Gunn and his OGC crew were so caught up in the BVA argument about Mr. Moye’s apparent disagreement with the way the facts were decided that they lost sight of the bigger picture. The law is fairly dispositive that if the glove don’t fit, you ain’t gonna convict. The OGC folks had put all their apples in the wrong basket and depended on the military’s MEB and Richard’s own admission that he had a problem. So blinded were they by this ” clear and unmistakable rightness” that they overlooked the fact that it was not the VA that had made the finding but the military. Apples in the oranges basket doesn’t work.

With regard to the evidence cited by the Board, the MEB findings are evidence that Mr. Moye’s pes planus pre-existed service and was not aggravated by service. But there is no indication that the MEB findings were predicated on a review of the totality of the evidence, or used the standard of “clear and unmistakable” evidence, and the Secretary has not submitted any evidence that such was a regular practice of the military services. Moreover, absent any discussion supporting the MEB findings, they are rendered suspect by other contemporaneous record facts, to wit: Mr. Moye

(1) entered service and was physically evaluated upon entry, with no indication that he had pes planus,

(2) was medically examined for foot problems on many occasions while in service, with no diagnosis of pes planus until more than six months after he entered service and no indication on that report that pes planus existed before service, and

(3) was not present to provide evidence or argument at the MEB proceedings.

NVLSP_Amy_136_203_70

Amy F. Odum, Esquire

The amazing part of this is that there is no available record to peruse so as to ascertain just exactly what the thinking of the rater was. Mighty convenient, too. It’s better than having a fire at the NPRC (with no sprinklers or smoke detectors) on Friday the 13th of July, 1973 after everyone has gone home for the day.  Nevertheless, Mr. Moye, assisted by his shield bearer and esquire Amy F. Odom, has prevailed because VA was, is and presumably always will be, sloppy, uninformed and prone to error. The reason is elementary- they are untrained in the school of law just as much as you or I. It only becomes apparent when you arrive at a real Court where they read the statutes and regulations instead of making them up as they go along to fit the facts.

0916-corvette_full_600Mr. Moye will soon be down at the Chevrolet dealership making those painfully hard choices on which color of Corvette he and the wife can agree on. The mortgage, if they refinanced in the early 2000s, will probably be retired or substantially reduced. Rest assured that he also faces the very real prospect of the 0% empty popsicle stick from 1979 in an adversarial Fenderson staged ratings reenactment. But what the hey? That’s why he hired Amy. I bet her phone is going to be ringing off the hook pretty soon. For your information, she works at the National Veterans Legal Services Program (NVLSP). No coincidence there. That’s the stable from whence Meg Bartley emerged before her ascension to Sainthood at the Court.

Posted in CAVC ruling, CUE, Presumption of Regularity | Tagged , , , , , , , , , , , , , , | 2 Comments

FACEPLACE THIS WEEK

10374883_10152433183905700_1670100692000661980_nHere’s a roundup of the good ones I spotted. They are, for the most part, getting pretty skinny this summer with everyone going on vacation.  

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SOVALDI–THE NEXT GENERATION OF HCV CLAIMS

download (1)I have recently been contacted more times than I can count by Veterans with the “What if I go SVR during my claim?” or the “How will this affect my rating now that I am cured?” Quite simple, actually. 38 CFR Part 4 dictates what is required for what percentage but some other guidelines apply depending on your claim date and your residual symptoms. Let’s analyze the possibilities all the way from very old to very new and the permutations of “residuals”.

An old example would be me. Due to VA’s recent munificence, I am a twenty year protected Vet and am bulletproof. My claim date of March 1994 guaranteed that but there are other metrics to gauge this by too.

If you are over ten years with P&T with a protected DIC for the oke-san, again, the DIC cannot be rescinded. VA would rarely try to disturb this or your P&T via the five-year rule.

If your claim is five years and older with 100%P&T, again this is a substantially protected position to defend. The five-year language in 38 CFR §3.344(c) is benign towards those who are not going to improve:

 (c) Disabilities which are likely to improve. The provisions of paragraphs (a) and (b) of this section apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.

And then there are the less than five year crowd who emailed me.

Many of you, including attorneys, tend to overlook some of the meat in 38 CFR § 3.340 that you can ultimately use to extract a P&T or 100% schedular rating you can turn into P&T.  Read the fine print:

b) Permanent total disability. Permanence of total disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. The permanent loss or loss of use of both hands, or of both feet, or of one hand and one foot, or of the sight of both eyes, or becoming permanently helpless or bedridden constitutes permanent total disability. Diseases and injuries of long standing which are actually totally incapacitating will be regarded as permanently and totally disabling when the probability of permanent improvement under treatment is remote. Permanent total disability ratings may not be granted as a result of any incapacity from acute infectious disease, accident, or injury, unless there is present one of the recognized combinations or permanent loss of use of extremities or sight, or the person is in the strict sense permanently helpless or bedridden, or when it is reasonably certain that a subsidence of the acute or temporary symptoms will be followed by irreducible totality of disability by way of residuals. The age of the disabled person may be considered in determining permanence.

We have a shifting dynamic on this that ensures a case-by case basis for grants, downward ratings or revisions but the age milestones are protections that are “backflow preventers”.  We know that once we hit the TDIU or 100% schedular wall, we are generally rescheduled for a final C&P to ascertain any improvement after two years. Absent any, we get the P&T designation and a small umbrella of protection. The five-year mark, although an arbitrary milestone, is generally accepted as the boundary of good taste for trying to claw back your protections accorded you via the P&T rating.

And then there are the newly rated. And the liver transplant crowd like Leigh. And on and on. Let’s take Hepper 74 in the “Get High or Die” state of Colorado. We share that left-handed tobacco distinction as I live in the Soviet Socialist Republic of Washington. Randy is blowing a Stage 4 on the hepometer like me. He is recently TDIU  and on appeal for 100% schedular under DC 7354. He’s getting on the Sovaldi Bus this morning. I’m one day ahead of him. My DEROS (Date of Return Off Sovaldi) is December 23, 2014. On paper, at least, but more about that in a minute.

Randy runs the risk of falling into the newly rated but not P&T group-i.e. less than five years. He need not worry. Even if he slays the dragon during his BVA appeal, the Shedden elements were and are met that he filed with the disability and the claim is predicated on what he had at the beginning, not what transpired in between or where he is when the appeal is finally granted. Given that the BVA is more backed up than a monkey who ate a pound of cheese, he’ll probably be on the cusp of five years by then anyway. And then we are going to mention residuals. But first, all you transplant folks.

Leigh of the East, my trooper who has slogged all the way to the CAVC just to extract her abbreviated c-file, is our poster child for liver transplant claims. Her claim is wisely grounded in an HCV claim rather than one of the convoluted cirrhosis claims under Diagnostic Code 7312.  The transplant just cements the gravity of how bad the HCV actually became. When you have to drop a new engine in or replace the transmission on a newer model car, you know it was defective for a long time. Looking back for the predominant risk factor is not a complicated exercise in forensics for those of us who served in the 60-90s. And then the residuals…

Here’s the big kicker in all these cases and brings them together. HCV, Interferon and Ribavirin treatments over the decades have taken their toll. Some of us have thyroid cancers, hypothyroidism, Diabetes Mellitus Type 2, Cryoglobulinemia, Porphyria Cutanea Tarda, kidney stones like hailstorms, Rheumatoid Arthritis, Fibromyalgia, gastrointestinal issues like Crohn’s or Ulcerative Colitis, ad nauseum. In short, but for the disease and the horrible side effects of the treatment, we wouldn’t be sailing on this ship. Residuals are the jetsam that has washed up on our beaches and now infest us.

nrmicro3046-f2Sovaldi is much like a birth control pill. It interrupts one of the six reproductive cycles of the disease and makes it easier for the human immune system to spot and eradicate the one version of the bug left. HCV is like a chimera that constantly metamorphoses ever so slightly so as to make itself unrecognizable. The Sovaldi does a “freeze-frame” on it and prevents any new mutations from evolving. As such, the side effects of Sovaldi alone are reportedly negligible. The Ribavirin and the Interferon are a different matter entirely. Hundreds of thousands of you are still alive to report that much.

Back in the old days, Mark (Hepsick) can tell you about the Interferon roundups. It was akin to surviving a nuclear war and left you slightly decayed and glowing in the dark. That was just the Interferon in its own right. The newer combination with Ribavirin was even more insidious and brought you to your knees whether you achieved SVR or not. Worse, the success rate was like Las Vegas. It almost killed him and he has many residuals that would render the majority of us 100% disabled in their own right. The HCV just ensures it’ll be a bad hair day every day. Removing the virus doesn’t obviate the need for the insulin shots and the dietary vigilance needed to stay afloat nor does it resolve the deep arthritic aches and pains we will always suffer from. These will never disappear but merely be magnified later in life. This is one of the primary reasons VA is going to have a hard time downrating you after SVR. Additionally, what, exactly is SVR? Will it come back in two or three years? Nobody knows. Sovaldi and the whole class of NS5A inhibitors haven’t even been around for three years yet. We’re in relatively uncharted waters yet our doctors would have us believe we’re sailing around in our own bathtubs.

As for some of the autoimmune issues generated by HCV, my doctors smile and say noncommittal things like “Well, I guess we have our fingers crossed on that one” or “It will be interesting to see if they resolve after treatment.”  Not one has said “We don’t have an escape hatch built into this for you AIH guys. Sorry.” The current game plan, much like the old one, is damn the torpedoes and full speed ahead. And once you start, you can’t stop. We now know there is a strong correlation between things like AIH and HCV but the danger of treatment is compounded by the danger of death. In the interests of science, we are apparently requested to “go along with it” unless it threatens to kill us. Sweet.

Things got so crazy in 2010 that my VA “hepatologist” ARNP Eileen Hanson greeted me for my 3 month check up and said “Wonderful news, Buckwheat! We have a cure called Telaprevir. We use it in conjunction with Ribavirin and Interferon”. This is the triple-drug wonder therapy that almost killed WGM down in Texas after two doses back in 2012. He’s clinging to life and his residuals are right off the map. His wife had to quit work to become his full-time caregiver. Eileen also knew I was Interferon-intolerant. Hell, that never stopped VA nurses or doctors. One size fits all in their book.

When I found out about Sovaldi (or Sofosbuvir) last spring, I immediately got in line for the trials. To my chagrin, Gilead didn’t want any AIH guys to queer the results for acceptance. Only a select few were chosen that fit into narrow parameters in order to arrive at a good outcome (early acceptance by the FDA). Someone like me (with AI issues) who tried this might upset the applecart so I was given the wave-off. However, the doctor hastily insisted that once Gilead Science launched the drug commercially that I could promptly get in line for treatment. Seems rather strange to prescribe drugs like that. We know the effects of Interferon and Ribavirin on autoimmune issues. I got a first-hand, close-up look at it in 2007 and and it almost killed me with one dose. What is remarkable is that everyone in the medical field seems to think Ribavirin is benign and only attacks the virus itself, or in the alternative, amplifies the action of Sovaldi. I disagree-as do my pharmacist and any number of folks who have eaten it for long periods of time. Read this:

More specifically:

Contraindications

Ribavirin tablets are contraindicated in:

•
Women who are pregnant. Ribavirin tablets may cause fetal harm when administered to a pregnant woman. Ribavirin tablets are contraindicated in women who are or may become pregnant. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus [see Warnings and Precautions (5.1), Use in Specific Populations (8.1), and Patient Counseling Information (17)].
•
Men whose female partners are pregnant.
•
Patients with hemoglobinopathies (e.g., thalassemia major or sickle-cell anemia).
•
In combination with didanosine. Reports of fatal hepatic failure, as well as peripheral neuropathy, pancreatitis, and symptomatic hyperlactatemia/lactic acidosis have been reported in clinical trials [see Drug Interactions (7.1)].

Ribavirin tablets and peginterferon alfa-2a combination therapy is contraindicated in patients with:

•

Autoimmune hepatitis.

•
Hepatic decompensation (Child-Pugh score greater than 6; class B and C) in cirrhotic CHC monoinfected patients before treatment [see Warnings and Precautions (5.3)].
•
Hepatic decompensation (Child-Pugh score greater than or equal to 6) in cirrhotic CHC patients coinfected with HIV before treatment [see Warnings and Precautions 

Seems this is some pretty serious stuff if it is in the same class as Thalidomide.

download (2)Ribavirin is contraindicated in the presence of autoimmune disorders and especially autoimmune hepatitis (AIH).  That much we know. Doctors try to decouple that by saying this interesting phenomenon of runaway autoimmune syndrome is due solely to Interferon.  Nevertheless, the Ribavirin monogram specifically mentions it as a culprit. How, then, can the doctors feel comfortable about prescribing it knowing full well they could be condemning the patient to death? Simple. They recite their little mantras like “Extremely interesting it will be to see how your body reacts. Yessssss. If there is a problem, we can discontinue the prophylaxis. Mmmmm. Put you on Budesonide (steroids) and Imuran (immune suppressant) we shall. Yesssssssss.”

In all this rush to medicate, nobody considers the double whammy. Consumption of the two drugs above (prednisone and Imuran) suppresses the autoimmune function of the body- the very white blood cells combatting the HCV infection.  Unfortunately, by suppressing one, you allow the other to run amok unimpeded. Someone should acquaint these boys with Newton’s Third law of Medical Physics. The current medical philosophy says pretty much what it said in the 90s and the 00’s- let’s run them down the Interferon cattle chute helter skelter and see how many make it. Sure, there’ll be some casualties but what the hey? We all benefit. Now they want to do a similar cattle drive to the Sovaldi ranch and brand us again -with the same, known drugs that cause blindness and DM2. Nary a one of them blinks an eye when queried about the inherent dangers. I doubt they understand the concept.

There are some interesting studies out with all the different combinations of how you can take Sovaldi. Gilead even ran a trial of twelve weeks using only Sovaldi. This Electron2 trial, as it was called, had a success rate of 64% or 16 of the 25 subjects attained SVR-in a mere twelve weeks.  This trial only included Genotype 3 subjects. The GS-7977 trials (all three of them) attained a uniform 82% using Sovaldi and Ribavirin for 24 weeks. Read more simply, in DickandJaneSpeak, it means adding Ribavirin and twelve weeks onto the treatment only resulted in an increase of 18% success in the recipients. If I didn’t know any better, I’d say someone was stuck with a shit ton of Ribavirin and looking for a place to unload it before the financial bottom falls out of it as it has with Interferon and Telaprevir/Boceprevir.

I’m on day 2 of the treatment so it will be interesting to see how things play out. The AIH is always at the back of my mind. I’ve waited 7 years for this and am not inclined to wait any longer. The danger of another napalm strike on top of the AIH to my immune system lurks in the wings with Ribavirin and the doctors consider this “a remote possibility” and “We’ll cross that bridge when we get to it”. Hold the phone, dude. We’ve arrived at the Rubicon and you’re behind me at the other end setting fire to it. How does that work?

download (1)One last observation. We talk of time as in 30 days have September, April, June and November. Apparently, in MedicalWorld, there are always 28 days in a Sovaldi month. Sovaldi comes in 28-pill bottles. Over six months, that amounts to twelve pills (or twelve days). On the Nasdaq exchange that translates out to $12,000.00 based on Gilead’s sales price of $1000.00 per pill. Who says there isn’t shrinkage in the medical sense? If Medicare gets billed $180,000.00 for my six month treatment, who gets to rake off the $12 K? Is this like a VA bonus regardless of whether or not you achieve SVR? I asked my Sovaldi minder ARPN Tobi how that works. I got the same identical shrug of the shoulders as I did when I asked what happens if my AIH goes apeshit on Ribavirin.

One thing is certain. VA will not move too soon on this. There seems to be a movement afoot at the BVA that signals an acceptance of the jetguns as the cause of this disease. It may be a fluke as there are so few of us left. Chances are that they will poke and prod a few, newer cases or ones in the pipeline in an attempt to set some kind of strictures on the newly-healed. Considering the number and severity of the residuals, I think it will be short lived. What’s to be gained from downgrading your Hepatitis C from 60% to 40% if you just turn around and file for fibromyalgia, rheumatoid arthritis, hypothyroidism and Cryoglobulinemia and end up back at the same rating of 100% combined or TDIU? It’s six of one and half a dozen of the other. Besides, the VHA has taken the liberty of admitting all these residuals are part and parcel of HCV and Interferon therapy. What’s to be gained? Well, boy howdy. You haven’t been around the VA as long as I have. Watch. These chowderheads can’t leave well enough alone.

 

 

Posted in HCV Health, HCV Risks (documented), Sofosbuvir | Tagged , , , , , , , , , , , , , , , , , , , , , | 25 Comments

BVA–THE SQUEAKY WHEEL THEORY

downloadFor years and in my book, I’ve tried to impress on VA claimants the absolute necessity for continuing to pound home the appeal-even if it involves remand after remand after Joint Motion to Remand. Here it paid off in a unique decision all of us can utilize. Print it up and hand it to you nexus doctor.  Several passages are gold for our claims. To wit:

The Veteran’s attorney submitted an October 2012 statement from a private physician. This physician disagreed with the findings of the August 2012 opinion of the physician’s assistant. He reported a brief explanation and history of Hepatitis C infection, noting that it is usually asymptomatic. He reported that the virus was initially isolated in 1989 and a reliable test was not developed until 1992. He stated that the virus is transmitted blood to blood, usually by tattoos, infected needles, razors, blood transfusions, etc. He added that the acute phase was 6 months and that the person was usually asymptomatic. Further, in approximately eighty percent of infected individuals, the antibody is detectable about 3-15 weeks after infection. He also referred to April 2000 medical testimony presented before the Subcommittee on Benefits on Veterans Affairs, which noted that one out of every 10 veterans were infected with Hepatitis C virus (HCV)), which is a rate five times greater than the 1.8 % infection rate of the general population. In addition he noted a 1999 Veterans Health Administration Study that found that 10 percent of veterans were infected with Hepatitis C.

This physician also noted that you need only one drop of blood of infected blood to come into contact with the blood stream, which can happen with a small nick of a razor or with micro tears in the gums of your mouth. The virus does not have to be directly injected into the veins. He reiterated that the Board conceded that he was exposed to blood while on active duty.

He stated that he disagreed with the findings of the VA examiner in August 2012 regarding the absence of documented treatment for Hepatitis C for an extended period of time after service discharge. He noted that a reliable test for Hepatitis C was not developed until 1992. Moreover, Hepatitis C does not manifest as an acute illness upon contraction of the virus and is usually not detected until decades later when there is late stage liver damage. As such, the VA finding that the lack of a diagnosis of Hepatitis C for nearly 35 years should not apply.

In addition he disagreed with the VA examiner’s reference to the Veteran’s post service high-risk activity. He stated that the Veteran would have had to share intranasal devices contaminated with Hepatitis C and have an open portal of blood entry in his nares. The physician found that there was a much higher chance of contracting Hepatitis C from such in-service activity as multi-injection air gun than any intranasal transfer from drug use. Finally he disagreed with the VA examiner’s statements regarding the fact that the Veteran’s military service represented approximately five percent of his adult life. He argued that regardless of the percentage of time the Veteran spent in the military, he was exposed to blood (as conceded by the Board), then it is just as likely as not that he contracted Hepatitis C while in-service. He stated that “[it] would be impossible for anyone to say specifically which route caused his Hepatitis C infection. There is no way to pinpoint one of those modes of transmission as the only factor.”

Well, there you have it. The first admission by a medical professional that a jetgun is far more lethal than a coke straw. Well, duh.

So:

RO Denial in 2008

BVA remand in 2009

BVA denial  in December 2010

Court JMRs the BVA in April 2011

BVA remands again in September 2011

BVA denies again in December 2012

Court vacates BVA denial and JMRs to the Board again in August 2013

BVA reverses and approves SC May 2014.

Now, just imagine if he had not had Rule 900 and an advancement on the docket? This old boy would either be dead or still sitting at St. Pete’s awaiting the first of those BVA remands from back in 2009. Ain’t justice a wonderful thing when it works?

imagesBookmark this one under “One Drop of Blood”. It’s about time they realize what a lethal disease factory we are. With ten pints of blood, you could theoretically contaminate every man woman and child in America.  At the VA, you could only infect yourself if you shot up or snorted the Devil’s dandruff.

And a warm thank you of appreciation to Kathy Lieberman, Esquire for her bang up job of rainmaker for this gentleman Vet.

Posted in BvA HCV decisions, HCV Health, HCV Risks (documented) | Tagged , , , , , , , , , , , , , , , , , , , | 3 Comments

BVA–PURE JETGUN DECISION

GaryJETBasicHere is what appears to be a straight forward jetgun decision. No prevarications. No hemming and hawing. No benefit of the doubt. Two doctors say it was jetguns and no one from VA stands up and says otherwise. This further vindicates my thesis that if you arrive with a pair, VA will probably fold. Here. they denied until the BVA reversed. And not only that, a veteran Veterans Law Judge was the one who did it. Shane Durkin was ricocheting around the BVA for decades as a staff attorney long before he became a VLJ. This is no flash in the pan.

P.S. Here’s another one. Again, no “resolving any benefit of the doubt in favor of the Vet” language. Just a simple ” It was the jetguns”.

Posted in BvA HCV decisions, Jetgun BvA Decisions, Jetgun Claims evidence, Nexus Information | Tagged , , , , , , , , , , , , , , , , , , | 2 Comments

BVA–LITTLE THINGS THAT YOU DO

downloadI always look for explicit examples of VA tricks and try to advertize them as a “Buyer Beware”. VA has a propensity to stretch the truth like no other agency of government. They have a tendency to cite to medical evidence as well, that, on it’s face, would not ordinarily be questioned…unless… well, if its seventeen years old. What’s disconcerting is that if and when called on it, the VA examiner will simply says something inane like “Oh, gosh. I guess I accidentally picked up the wrong Dorland’s manual”. Which would beg an explanation of why the old one is still on the shelf in any normal investigation of misfeasance. 

Poor Jane Vet here from the Cigarette Regional Office of Winston tastes good like as a Salem should, discovers this much to her dismay. Seems she did a bang up job of presenting secondaries to her now-connected Hepatitis C. The VA examiner, in what is quite obviously denial mode, searched long and hard to find supportive literature that would dissuade the Veterans Law Judge. And find that supportive literature he did. Nonplussed, Jan appealed. Smart cookie. And much like the song by Billy Gilman, the little things that the VLJ did made Jane glad she appealed.

Considering the VA is a cutting-edge medical organization with all the most up-to-date tomes on Cecil, Book or Medicine and Dorland’s Medical Dictionary, one would find it almost inconceivable that an examiner would be forced to quote outdated medical literature to write a cogent denial. The reason we know this is simple. When reading denials of this type, we see the cite to which year the VA examiner is referring- i.e. Dorland’s (1997). Here, we must assume the VA examiner made the grievous error of actually citing the reference material in such a way as to unveil his/her  grotesque attempt at subterfuge.

Always remember this quirk. Add it to your list of “VA Denial techniques”. We all know they are forced to go farther and farther afield in their attempts to deny but this one is a newer variation. Hepatitis C is unique in many regards. Being cryptogenic, it can lie hidden for decades and we can now defeat the Maxson v. Gober holding. Similarly, we know it is uniquely linear in its progression which allows us to date it within a certainty of a few years of inception. That put a fork in the VA Examiner’s warped logic of stating that there was no evidence of Hepatitis C in the Veteran’s SMRs from 1967. Each of these medical revelations have allowed us to gradually improve our odds of winning. Thus it should come as no surprise that VA will go to any lengths to poke holes in any claims endeavour-even horribly logical, medically-supported ones- that purport to prove a link to the primary disease.

The Veteran contends that she currently experiences GERD, IBS, polyarthritis, and chronic headaches, as a result of hepatitis C. In this regard, the November 2012 VA examiner opined that the weight of the current medical literature was against a nexus (less likely than not) between hepatitis C and the remaining issues of GERD, IBS, polyarthritis and headaches. The examiner noted that those specific conditions had a number of possible etiologies or may be idiopathic in nature, but none of them were shown to have a plausible nexus to hepatitis C per the current medical literature. The examiner cited to medical literature dated in 1997 as support for the opinion. In response to this opinion, the Veteran submitted more recent general medical literature indicating a possible relationship between (1) chronic hepatitis C and IBS; (2) fibromyalgia and IBS; and (3) rheumatic arthralgia and hepatitis C. The literature, most of which is dated subsequent to 2007, suggests that the findings of the November 2012 examiner may be based on outdated medical findings given that the support for his opinion comes from medical literature dated in 1997, a decade before the medical literature submitted by the Veteran in support of her claims. Thus, the November 2012 examiner’s opinion should be revisited in light of the newly received evidence, and the Veteran should be afforded another VA examination to determine the current nature and likely etiology of the GERD, IBS, polyarthritis, and headaches. Significantly, the examiner should determine what symptoms are associated with each condition, particularly given that the November 2012 examiner provided a positive nexus opinion between the hepatitis C and the fibromyalgia.

We have to assume that the “acting” VLJ, A.C. Mackenzie wants to be anally correct and get it right because she’s new to this judging business. Several years from now, she’ll be firmly ensconced in the saddle and this will never happen again. By then, 1997 medial literature, in her book, will be compelling, cutting-edge, accepted medical evidence and the denial will be affirmed.

One reason Jane Vet prevailed here is obvious. Absent a VSO minder to steer her into a blind alley, she went it alone as a pro se claimant. I have nothing against lawyers (or VSOs for that matter). In fact, as most know, I extol their virtues. Here, Miz Jane seems adequate to the task so a rainmaker might be superfluous. This is all well and fine until you get to the rarified oxygen of  625 Indiana Avenue NW on appeal to the Court. Having a mouthpiece there is a must in my book.

images Lastly, let’s revisit the Presumption of Regularity in all things VA does. If we are to believe it, this is simply an oversight or a glitch in the ratings protocols. Likewise, if believing it, we are expected to swallow the pablum that’s it’s a good thing Jane Vet was up to speed on the latest in medical science.  Ignorance was thwarted and Justice was accomplished ergo they all lived happily ever after. Pray tell, with all that is afoot at the VA these days, how can there be any Presumption, other than the one of Ineptitude, VA can get anything right?

The river of deceit, the plethora of bonuses and the gross mis/malfeasance we are seeing uncovered daily contradict everything we could possibly depend on to support our confidence in their system. But then, knowledgeable Vets have known that all along…

Posted in BvA HCV decisions, HCV Health, HCV Risks (documented), Tips and Tricks | Tagged , , , , , , , , , , , , , , , , , , | 2 Comments