Secondary Service Connected Conditions & Medical Opinions

1. Secondary Service Connected Conditions & Medical Opinions Paula Taylor / Abdullah Shamsid-Deen Fall Conference, 2009

2. SECONDARY SERVICE CONNECTED CONDITIONS • WELL-GROUNDED CLAIMS • SERVICE-CONNECTED • NONSERVICE-CONNECTED

3. SECONDARY SERVICE CONNECTED CONDITIONS WAYS TO ESTABLISH SERVICE-CONNECTED CLAIMS • DIRECT SERVICE-CONNECTION • AGGRAVATED PRE-EXISTING CONDITION • PRESUMPTIVE SERVICE-CONNECTION • 1151 CLAIMS • SECONDARY SERVICE-CONNECTION

4. SECONDARY SERVICE CONNECTED CONDITIONS SECONDARY SERVICE CONNECTION REFERENCE: 38 CFR 3.310

5. SECONDARY SERVICE CONNECTED CONDITIONS38 CFR 3.310 States: •  I. Disabilities caused by a service-connected disability will be service connected on that basis •  II. Also, Non-service connected disabilities made • worse by a service-connected disability, IF ... a. Medical evidence that pre-dates the worsening establishes the baseline level of the disability b. Current severity is worse than the baseline, which is to be deducted from the overall rating •   c. Current medical evidence cannot establish the baseline 

6. SECONDARY SERVICE CONNECTED CONDITIONS EXAMPLES OF SECONDARY CONDITIONS • Right Knee, Secondary to Left Knee • Lower Back, Secondary to Knee(s) • Lower Back, Secondary to Pes Planus • Sexual Dysfunction, Secondary to PTSD • Depression, Secondary to Occipital Nerve Injury

7. SECONDARY SERVICE CONNECTED CONDITIONS EXAMPLES OF SECONDARY CONDITIONS(CONT’D) • Kidney Failure, Secondary to Hypertension • Other Secondary Hypertension Conditions? • Glaucoma, Secondary to Diabetes Mellitus • Other Secondary Diabetes Conditions ?

8. SECONDARY SERVICE CONNECTED CONDITIONS ESTABLISHING SECONDARY SERVICE-CONNECTION REQUIRES: • Sufficient evidence that a current disability was caused or aggravated by a “service-connected” disability • Since this is a question of Medical Causation, competent individuals possessing specialized training and knowledge must to render a “Medical Opinion”

9. MEDICAL OPINIONS MEDICAL OPINIONS 38 CFR 3.159 COMPETENT MEDICAL EVIDENCE MEANS EVIDENCE PROVIDED BY A PERSON WHO IS QUALIFIED THROUGH EDUCATION, TRAINING,OR EXPERIENCE TO OFFER MEDICAL DIAGNOSES, STATEMENTS, OR OPINIONS. COMPETENT MEDICAL EVIDENCE MAY ALSO MEAN STATEMENTS CONVEYING SOUND MEDICAL PRINCIPLES FOUND IN MEDICAL TREATISES. IT WOULD ALSO INCLUDE STATEMENTS CONTAINED IN AUTHORITATIVE WRITINGS SUCH AS MEDICAL AND SCIENTIFIC ARTICLES AND RESEARCH REPORTS OR ANALYSES.

10. MEDICAL OPINIONS COMPETENT MEDICAL EVIDENCE • EDUCATION, TRAINING, OR EXPERIENCE • DIAGNOSES, STATEMENTS, OR OPINIONS • MEDICAL AND SCIENTIFIC ARTICLES • RESEARCH REPORTS OR ANALYSES

11. MEDICAL OPINIONSWHEN WILL VA REQUEST A MEDICAL OPINION THE RECORD DOES NOT CONTAIN SUFFICIENT COMPETENT MEDICAL EVIDENCE BUT: • CONTAINS COMPETENT EVIDENCE OF A CURRENT DIAGNOSED DISABILITY OR PERSISTENT OR RECURRENT SYMPTOMS OF DISABILITY • ESTABLISHES THAT THE VETERAN SUFFERED AN EVENT, INJURY OR DISEASE IN SERVICE OR HAS A DISEASE OR SYMPTOMS OF A DISEASE LISTED IN 38 CFR 3.309, 3.313, 3.316, AND 3.317 • INDICATES THAT THE CLAIMED DISABILITY OR SYMPTOMS MAY BE ASSOCIATED WITH THE ESTABLISHED EVENT, INJURY, OR DISEASE IN SERVICE OR WITH ANOTHER SERVICE -CONNECTED DISABILITY

12. MEDICAL OPINIONSWHY WOULD VA REQUIRE A MEDICAL OPINION • TO RECONCILE DIAGNOSES • TO DETERMINE THE RELATIONSHIP BETWEEN CONDITIONS • TO DETERMINE THE ETIOLOGY OR NEXUS TO SERVICE-INCURRED DISEASE OR INJURY • TO DETERMINE WHETHER AND TO WHAT EXTENT A SERVICE-CONNECTED DISABILITY HAS AGGRAVATED A NONSERVICE CONNECTED CONDITION

13. SECONDARY SERVICE CONNECTION &MEDICAL OPINIONSREQUEST FOR MEDICAL OPINION ISSUES: CONTENTION: AVAILABLE PERTINENT EVIDENCE: SERVICE MEDICAL RECORDS: PRIVATE MEDICAL RECORDS: VA RECORDS OTHER: REQUESTED OPINION: NOTE TO EXAMINER-IN YOUR RESPONSE PLEASE: 1. IDENTIFY THE SPECIFIC EVIDENCE YOU REVIEWED AND CONSIDER IN FORMING YOUR OPINION. 2. PLEASE PROVIDE A RATIONALE (EXPLANATION/BASIS) FOR THE OPINION PRESENTED 3. STATE YOUR CONCLUSIONS USING ONE OF THE FOLLOWING LEGALLY RECONGNIZED PHRASES:

14. MEDICAL OPINIONS LEGALLY RECOGNIZED PHRASES • Is Caused By Or A Result Of__________ • Is Most Likely Caused By Or A Result Of__________ • Is At Least As Likely As Not(50/50 Probability) Caused By Or A Result Of__________ • Is Less Likely As Not (Less Than 50/50 Probability) Caused By Or A Result Of__________ • Is Not Caused By Or A Result Of__________ • I Cannot Resolve This Issue Without Resorting To Mere Speculation

15. MEDICAL OPINIONS MEDICAL RATIONALE IT IS ESSENTIALLY AN EXPLANATION OF HOW THE PHYSICIAN ARRIVED AT HIS OR HER MEDICAL OPINION AND SHOULD CONTAIN, AS A MINIMUM, AN EXPLANATION OF THE PATHOLOGICAL OR OTHER MEDICAL RELATIONSHIP BETWEEN THE CURRENT DIAGNOSES AND THE INJURY IN SERVICE OR CURRENT DIAGNOSIS AND THE SERVICE CONNECTED DISABILITY

16. MEDICAL OPINIONS EXAMPLE ISSUE: ENTITLEMENT TO SERVICE CONNECTION FOR CARDIAC DISORDER, ORIGINALLY CLAIMED AS MYOCARDIAL INFRACTION, SECONDARY TO THE SERVICE-CONNECTED DISABILITY OF ANXIETY DISORDER: OR, IN THE ALTERNATIVE, SECONDARY TO A TOBACCO USE DISORDER, ORIGINALLY CLAIMED AS CIGARETTE SMOKING, SECONDARY TO THE SERVICE-CONNECTED DISABILITY OF ANXIETY. FACTS: VA AND PRIVATE MEDICAL EVIDENCE OR RECORDS SHOWS THAT THE VETERAN HAD A MYOCARDIAL INFARCTION IN 1995 AND HAS A CURRENT DIAGNOSIS OF ATHEROSCLEROTIC CORONARY ARTERY DISEASE.

17. MEDICAL OPINIONS EXAMPLE CONT: July 2002-VA Comp And Pen Examiner Opined Less Likely Caused Or Aggravated By the Service Connected Anxiety July 2002-VA Psychologist Opined As Likely As Not That The Veteran’s Heart Problems Are Aggravated By His Anxiety August 2002-VA Psychologist Explained That the Limitation Of Life That Affected The Veteran Because Of The Heart Disease Felt Worse To The Veteran Because Of His Anxiety Disorder. (The Physician Based The Opinion On A Publication By The AmericanPsychological Association That It Was Possible That Heart Problems Are Aggravated By Anxiety)

18. MEDICAL OPINIONS EXAMPLE CONT: 2004: PRIVATE PHYSICIAN DIAGNOSED THE VETERAN WITH CORONARY ARTERY DISEASE. HE NOTED THAT STRESS AND ANXIETY AS A CONTRIBUTING FACTOR TO CORONARY ARTERY DISEASE WAS CERTAINLY A POSSIBILITY, BUT IT WAS NOT ENTIRELY CLEAR, AS IT WAS DIFFICULT TO DOCUMENT

19. MEDICAL OPINIONS WHAT DID THE BOARD DECIDE CONCLUSION OF LAW: A CARDIC DISABILITY WAS AGGRAVATED BY A SERVICE CONNECTED DISABILITY ORDER: ENTITLEMENT TO SERVICE CONNECTION FOR CARDIAC DISORDER, ORIGINALLY CLAIMED AS MYOCARDIAL INFRACTION, SECONDARY TO THE SERVICE-CONNECTED DISABILITY OF ANXIETY DISORDER IS GRANTED

20. MEDICAL OPINIONS PRACTICAL EXERCISE OUTLINE ISSUES: REASONS AND BASES FOR FINDINGS AND CONCLUSION: (MEDICAL OPINIONS) DETERMINE THE DECISION: DETERMINE THE ORDER:

21. SECONDARY SERVICE CONNECTION &MEDICAL OPINIONS QUESTIONS

22. SECONDARY SERVICE CONNECTION &MEDICAL OPINIONS SUMMARY