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Blog Talk Radio.

J Basser: 0:04

It's time for the Exposed Vet Radio Show. The Exposed Vet Radio Show. We discuss issues affecting today's veteran. Now here's your host, john and Ray. Welcome, ladies and gentlemen, to the episode of the Exposed Vet Radio Show on this June 6, 2024. Today is the anniversary of the final battle of Midway, the final day. We all think back about that day that turned World War II into favor of the United States at the time. Today we've got Bethy Spangenberg on. She is a volunteer vet. She's the chief of the boss we're going to do another series of discussions.

J Basser: 0:50

We're going to do the DBQ. We're going to go over those painful, dreaded skin diseases. She's got a lot of information to pass out. Our co-host today is Mr Ray Cobb. He's traveling a little bit, but he's on the air. How are you doing, ray?

Ray Cobb: 1:05

I'm doing great. Yeah, it's a little warm out here where I'm traveling, but the scenery is gorgeous and I went to a place today called Fiery Valley and it was not only hot but all the rocks are beautiful, deep red.

J Basser: 1:24

Copper in them there. That's good Awesome.

Ray Cobb: 1:26

Yeah, a lot of copper.

J Basser: 1:28

Good. Well, Bethany, how are you doing tonight?

Bethanie Spangenberg: 1:33

I'm doing well. I've been busy this week with the kids and basketball camp and volleyball camp, and so, as of right now, we're enjoying the weekend.

J Basser: 1:45

So you got your weekend to the family itself with no extra activities, or what?

Bethanie Spangenberg: 1:50

Yes, and that's why I'm happy to be where we're at right now. It's been a long week.

J Basser: 1:55

Shut the doors, lock everything and just close it, turn the phones off and everything. Just do family time. Maybe get you some hamburgers and hot dogs and cookout or something you know I like that you know that would be good I like that there you go. But yeah, we're going to discuss the old, dreaded skin diseases, you know. But you go right ahead and take off or turn it over to you.

Bethanie Spangenberg: 2:17

Well, before we get too deep into it, Ray, are you going to visit the sequoia trees or the Sequoia Forest?

Ray Cobb: 2:27

No, we did that the last time we were out here. They're absolutely gorgeous. I think our next trip, though, we will go up there. We'll also hit a couple of the national parks over there in the California northern side of it yeah. They're actually beautiful. Northern side of it they're actually beautiful. They have one there known as the Robert E Lee, which is the largest and oldest in the forest. It's amazing.

Bethanie Spangenberg: 2:54

Yeah. I think that's something that you have to see in your lifetime. It's definitely something to add to the bucket list. We went out there probably 10 years ago now and I'm going to take the kids back, but it is unbelievable to see those trees Awesome. So I wanted to ask.

J Basser: 3:13

I think that's probably back in the 80s. I should go back to San Diego one week in a while. It's all that. It's a long trip. Yeah, yeah, we'll be from San. It's a long trip, yeah.

Ray Cobb: 3:26

Yeah, we'll be from San Diego, mm-hmm.

J Basser: 3:30

That's cool. No, it's beautiful.

Bethanie Spangenberg: 3:35

All right. Well, I just had to ask, since you mentioned you were in the area, but let's transition into the skin stuff again.

Bethanie Spangenberg: 3:44

So, last month, I think it was, we talked about the scarring and burn scars and disfigurement. This week or this month is skin diseases and specifically the rest of the skin rating schedule. And before I I'm going to do it backwards this time Instead of doing the DBQ first, I want to talk about the rating schedule because I think for the skin you really need to understand a little bit about the rating schedule. It's like foundational for understanding what is in the DBQ, because what's in the DBQ directly reflects what's in the rating schedule. I think it's important to start there with a little bit of foundation.

Bethanie Spangenberg: 4:30

So when we talked about burns and scars, we talked about eight characteristics of skin disfigurement and those eight characteristics carry over into the rest of the rating schedule for skin disorders. And then we also need to understand in the rating schedule how exposed skin versus non-exposed skin is defined. We need to understand what the VA views as systemic therapy versus topical therapy, the VA views as systemic therapy versus topical therapy. And then we also need to understand how they look at pyramiding for the skin condition. So we're going to cover each of those little areas before we dive into the DBQ. So those eight characteristics of disfigurement that we talked about when we discussed scarring and we're just going to briefly go over those but those carry into the reading schedule for other skin diseases.

Bethanie Spangenberg: 5:31

And the eight characteristics are that if a scar or skin condition is five or more inches in length. If a scar or skin condition is a quarter inch wide or greater. If the skin contour is elevated or depressed. If the skin sticks to the underlying tissue and it's fixed so it doesn't move. If the skin texture is abnormal and a surface area of greater than six square inches. If the underlying skin tissue is missing, the fat, tissue or vascular area under the skin and it's greater than six square inches, and if the skin is hard or inflexible in an area greater than six square inches. And so those different characteristics will give different ratings further down in the rating schedule. So just a reminder of what those are. When we look at exposed skin versus non-exposed skin, it's a little bit different than what we would think. Well, I'm wearing a t-shirt, my elbows are exposed.

Bethanie Spangenberg: 6:47

Well, the VA doesn't look at it that way. The VA considers the exposed skin to be the face, the neck and the hands. So even if it's on your elbows, they don't consider it exposed skin. If it's on your knees, they don't consider it exposed exposed skin. If it's on your knees, they don't consider it exposed. So, outside of the face, the neck and the hands, all of the other areas are considered to be non-exposed. Does that make sense I mean do you?

J Basser: 7:17

understand, not that it quite makes sense, but Well, I think you wear clothes, long sleeves and things like that too. That's what they do, living that Amish life. Yeah, this is a bit of some good furniture, right.

Bethanie Spangenberg: 7:43

So when it comes to understanding systemic therapy versus topical therapy, so systemic therapy, from a clinical standpoint, is something that is in the body and runs through the body, and the way the VA also recognizes it is whether the medication is taken orally, by injection, if it's used by either like a suppository, which is either vaginally or rectally, or if you're using it intranasally. So steroids, light therapy, immunosuppression, those are all considered to be systemic therapies and so, based off of the rating schedule, if you have systemic therapy, that might fall into a different criteria for your disability rating percentage. And then they look at topical therapy being any type of treatment that is administered through the skin and it's specifically meaning like topical cream, or sometimes even testosterone is topical where you put it on the skin. So they consider I mean, when we look at testosterone specifically, if you put it on the skin, that's topical. But testosterone also is available in injection and that injection is systemic therapy and a lot of medications can be given both ways and, depending on what treatment you're choosing for your skin condition, it may affect what you receive on your disability rating.

Bethanie Spangenberg: 9:09

The last thing I think is important to understand is how pyramiding is viewed for skin conditions. So if you have multiple skin conditions affecting one area, then you get the higher of the ratings. So, for example, if you have a burn scar affecting the chest and the back but you also have a skin fungus that affects the chest and the back, they're only going to give you one rating and it's going to be the higher of whatever condition. Now let's say you have acne on your face, you have a skin fungus on your chest and your back and you also have scarring on your left leg. You can receive separate ratings because it's affecting different areas of the skin. You guys follow me on that one, yeah. So that can be kind of confusing because you know when we start to really look at what these skin conditions are affecting, sometimes the math can be difficult to calculate. You know how much of the skin condition is covering certain parts of the body and we'll talk about that as we go through the DBQ.

Bethanie Spangenberg: 10:31

So now that we kind of understand those basic things that apply, those basic definitions that apply to the rating schedule, I want to dive into what they call the general rating formula for skin. So they have this general rating formula that most of the skin conditions fall under and if there's a skin condition that isn't specifically mentioned in the rating schedule, then it falls into this category. So they have, like, specific diagnoses that have specific ratings, and one example is acne. Acne has its own rating and then chloracne has its own rating. But other conditions that may not fall into the rating schedule as it's defined will be lumped into the general rating formula for the skin.

Bethanie Spangenberg: 11:31

So dermatitis or eczema falls under the general rating formula for the skin. Dermatitis and eczema are one of those that I was going to briefly talk about today as we go through the DBQ. That's diagnostic code 7806. And then dermatophytosis, or those are your fungal infections. So if you have atinia corporis, atinia cruis, there's your nail fungus, your athlete's foot, there's tinia versicolor. Those are all fungal infections and they fall under the general rating formula for the skin. So if you're listening and you may not have dermatitis, maybe you don't have a skin fungus, but you have any of the skin conditions that I'm about to talk about.

Bethanie Spangenberg: 12:36

I'm going to list all of them that fall underneath that general rating formula. You'll want to listen to see how it's rated. So the other conditions that are rated under the general rating formula is lupus, erythematosis and Ebola, skin disorders or skin disorders that blister, psoriasis, infections of the skin, including bacterial infections, viral infections, skin conditions that are associated with the collagen or vascular, like scleroderma, any type of disorders that create skin plaques, and any diseases involving how the skin sheds. There are some disorders that the body doesn't like to shed the skin, and so the skin will actually flake up or start to build up, and that is also covered under the general rating formula. So it's pretty broad. There's a lot there. There's several diagnostic codes that are covered, and so it's important to kind of understand how these are looked at. Any questions so far.

Ray Cobb: 13:51

These skin conditions that you've named. I've heard of several folks that have something like that. That wasn't even in the military. Are these basically from exposure of some type of a chemical that caused this, or how do you define that and identify it?

Bethanie Spangenberg: 14:11

So that's actually a great question. So I'm going to kind of break down a few of the diagnoses that I talked about. So if we look at dermatitis and eczema, those can be secondary to like a knee brace or an orthotic. If you wear like even some they call them AFOs from. We had somebody call in previously saying they wore AFOs to help with their foot drop. If that causes some skin irritation around the lower leg, that's a dermatitis. That may be service-connected. The eczema Eczema can develop from other autoimmune disorders the tinea or the fungus that we talked about. I've seen a lot of those come back from our more recent veterans where they're out in the desert and they're wearing all their equipment and they've actually they may have never brought it to anybody's attention. I remember doing a DPQ for a veteran that had just gotten out. I think it was actually a year after he'd gotten out and he was talking to me and I looked at the bridge of his nose and he had this flaky skin across the bridge of his nose and I asked him about it.

Bethanie Spangenberg: 15:33

I said, well, you know how long has that been there? What is that? He goes. You know, I don't know. I get a couple patches on my face and then he goes. It's actually all over my back, he goes.

Bethanie Spangenberg: 15:42

It started when I was deployed and so I looked at his back and I'm like, oh, I said that is what we call tinea versicolor. So it's a type of fungus that makes little patches of the skin, kind of crust around like the edges, but the inside is a little bit pale, a little bit wider. We call it tinea versicolor. The inside is a little bit pale, a little bit wider. We call it tinea versicolor. And here it was, from all the sweat and all the moisture and wearing his body armor and his face mask while he was in the desert. He's like, yeah, I had no idea, they didn't tell me anything and he wasn't there for conditioned DBQ, he was there for something completely different. And I was like, yeah, you need to go have your primary care doctor, either give you an antifungal for it or see a dermatologist if they don't give you an antifungal, but you should also apply for a service connection because that's consistent, your timeline is consistent and that's a known trigger for developing that type of fungus. So that's one example.

Bethanie Spangenberg: 16:49

We get a lot of foot fungus. We get a lot of the nail fungus within the nails. The foot fungus I'm talking about is from having wet feet and in your boots, so we got a lot of those. And then the nail fungus, where the nail actually gets really thick and it turns yellow and it's really hard. That's a foot fungus or a fungus within the nail, in the nail bed. A lot of times in order to treat that, you actually have to remove the entire nail and take an oral medication to get the nail to return to its normal appearance. And we see those with vascular diseases if there's not good circulation in the toes, whether it's from peripheral arterial disease, whether it's from vascular disease, which we've talked about in the past, and it even could be from diabetes.

Ray Cobb: 17:52

Question. With that. You just explained something that happened to me three years ago. I go in. The toenail is exactly what you said. It was thick, it was a dark yellow and my podiatrist removed it and then started me on a I guess it was an antibiotic and it returned to normal. Now how does that fit into a claim? I mean, if it's something that can be rectified, I guess is what term I would want to use. Then it's improved or gone away, correct?

Bethanie Spangenberg: 18:36

Yes, so it would just depend, like if you filed for it while it was active, then you would get some type of compensation during that period. It was active because you were being orally treated with medication.

Ray Cobb: 19:01

Now, once you're not on an intermittent medication or need the oral medication, then you drop to a zero.

Bethanie Spangenberg: 19:03

So if it reoccurs which with diabetes, you're going to most likely have it recur again. If you don't stay on top of the medication, or if it starts to recur, your doctor may put you back on that medication. Once you're on that systemic medication, then you become compensable depending on the duration then you become compensable depending on the duration.

J Basser: 19:28

Keep an eye on that nail next to your cuticle and your toe Ray, and if you feel it's got a ridge or raises up like a bunch or whatever of the nail, then that means it's not fully healed. It's not fully healed.

Bethanie Spangenberg: 19:40

Yeah, okay, any other questions?

Ray Cobb: 19:46

No, you just told me something I got that I didn't know I had.

Ad: 19:52

So, let's actually dive into it.

Bethanie Spangenberg: 19:56

It really does. You know, I actually I do. I do a lot of medical reading and medical research, with me being in the medical field and then doing the medical opinions, but then I also have type 1 diabetes. I'm constantly trying to learn and understand this disease and I'm trying to prevent the typical comorbidities so that I can be present for my children. That's probably what I live for is to be present for my kids, and so I'm constantly listening about how to prevent the complications.

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And.

Bethanie Spangenberg: 20:35

I heard something this past week about diabetes, and when you look at what they call the mitochondria, the mitochondria is the energy, the workhorse of our cells and how our bodies function, and so if you don't have healthy mitochondria, your body's not healthy. And so they looked at the mitochondria of individuals with diabetes and individuals with cancer and they could not tell a difference. That is how bad diabetes affects the body and the energy system of the body is that it could not tell the difference between somebody who had cancer and somebody who had diabetes. So I thought that was pretty shocking.

Ray Cobb: 21:24

Yeah, yeah so.

Bethanie Spangenberg: 21:29

So if we look into the general rating formula for this again, this is what I've been preaching about since we started and we're going to break down the actual ratings. And we talked a little bit with ray, with your condition, we talked a little bit about it, so let's look at it specifically. So if you're only using a topical therapy for the last 12 months and there is one characteristic that we mentioned, one of the eight characteristics involving less than five percent of the whole body, you get a zero percent. So let's say, for that foot fungus, let's say your provider didn't know what it was, or they wanted to try to use a topical treatment first, and it's less than 5% of the whole body and it only has the thickening of the nail, so the texture of the nail is abnormal. So you would qualify for a 0%.

Bethanie Spangenberg: 22:25

If there is characteristic lesions involving less than 5% of the exposed body. So in the face, neck or hands, you get 0%. Okay, so less than 5% affecting your body or the exposed area, you get a 0%. So, moving into the 10% categories, if there is characteristic the skin, if there's one of the eight characteristics I'm going to say characteristics a thousand times. I need a different word. If the skin condition has one of the characteristics and it's anywhere from 5% to 20% of the whole body, so it's covering, you know, 5% of your left leg and it's less than 20%, it's 5% up to 20%, that's 10% compensation. So if there's a characteristic lesion from 5% up to 20% of the exposed body, that's 10%. So if you look at the face, the neck and the hands and there is are you guys following me when I'm talking about the? There's a lot of percent, there's a lot of characteristics.

Bethanie Spangenberg: 23:54

So if they, have any yes, it is, and it's hard to try to reiterate and be understood. So they're trying to find a window of how much coverage of your body there is of this skin condition, so, and they're looking at the whole body and then they're also looking at the exposed body and then they're also looking at the type of treatment. So each percentage kind of breaks that down. So if there's intermittent systemic therapy for less than six weeks per year, that would be 10%. And that may be something where you're on the oral antifungal medication for your toenails. If that's an intermittent oral medication for less than six weeks, that's going to buy you a 10% rating.

Bethanie Spangenberg: 24:43

Okay, in the same pattern, looking at the percentages of coverage 20 to 40% of the whole body is 30%. Disability rating 20 to 40% of the exposed body is 30%. If you're on systemic therapy for more than six weeks but it's not constant over the last 12 months, then that's 30%. And then the top tier is if the skin condition is more than 40% of the whole body, that's a 60% compensation. More than 40% of the face, neck and hand, that's 60 percent compensation. And if you are on constant or near constant systemic therapy over the last year, that is a 60 percent compensation and I have seen some of those conditions for dermatitis or for eczema where they have to be on a regular immunosuppression to kind of tame that condition. So that's a lot. That's a lot of numbers to kind of spit out and try to explain for your dermatitis, eczema, your fungal infections and then anything that doesn't fall in the rating schedule specifically. Any questions about that?

J Basser: 26:25

What is like, for example? Right, we're talking about diabetes and you know where does it come into play, say, if you've got vascular disease or venous insufficiency. One of the characteristics of it is trophic changes in the skin, and it's where your skin gets real shiny, real dry and the hair just disappears. Does that cover that, or is that part of a separate process?

Bethanie Spangenberg: 26:53

So that does cover the characteristics portion that we talked about and it may qualify for the dermatitis under the general rating schedule they would have to consider. Are they looking at the skin changes as a part of a nerve disease or are they looking at it as part of the diabetes, because you can have where the neuropathy gets so severe that the skin becomes shiny and the skin loses its hair, and so they. I think, in my opinion, they'd have to look to see which would give you the higher rating.

J Basser: 27:36

Yeah, basically I think it's diabetic small fiber neuropathy and it's part of the autonomic process.

Bethanie Spangenberg: 27:43

Yes, that would be interesting because I think you'd almost, because you would technically get like what? 30% for a left leg neuropathy, a severe neuropathy with the autonomic changes or the skin changes. But I don't think you're leg would consume 40% of the whole body. So I think you're still better off going the neuropathy route. Or you may look at it and say, well, they're saying I have a mild neuropathy. Or you may look at it and say well they're saying I have a mild neuropathy but the skin changes cover more than 40% of my body, and so you may want to argue that it's a skin condition and you could probably get a higher rating with the skin condition.

J Basser: 28:47

It's not just legs, it's all the way from the wrist to the elbows too.

Bethanie Spangenberg: 28:53

Yeah, that's a great question. I've never, you know, I don't think I've ever seen it it filed either way. I don't think I've ever actually seen specific um like an application or a dbq request or exam request that specifically talks about the skin changes associated with diabetes. Now I've seen, you know, a lot of funguses come, requests come through from diabetics Even, like if you're diabetic and you have your skin fold where your belly sits on your legs and that creates a great place for fungal infections.

Bethanie Spangenberg: 29:36

I've seen veterans apply for those fungal infections and be compensated for that.

J Basser: 29:44

I hope those nipples will take care of that belly when he's down.

Ray Cobb: 29:52

It's working on mine pretty good.

J Basser: 29:55

Oh gosh, I mean, there's so many things, there's so many things. With diabetes it's unsanitable, especially with that kind of stuff going on. That makes it hard.

Ray Cobb: 30:09

Well, and what also is. I mean, for example, I'm 60% in both legs for diabetic neuropathy and then I've got a foot drop in both feet wearing an AFO, so I have two Ls and then those two 60 percenters. It would not benefit me whatsoever to turn a claim in then for the skin disease if the top is a 40 percenter, correct.

J Basser: 30:47

The top for skin is 60. Yeah.

Bethanie Spangenberg: 30:50

You're our team.

J Basser: 30:55

Until they invent an R3. No.

Ray Cobb: 30:57

That's how they go right.

J Basser: 31:03

I mean, you don't want to overthink it.

Ray Cobb: 31:05

as far as you can go Until like that nurse practitioner told Pam and I a couple of months ago now you got one foot in the grave and the other's on a banana peeling, and hold on when that banana peeling slips. That's when I can go to R3, huh, oh gosh.

Bethanie Spangenberg: 31:28

So now that I've explained, or I've tried to explain, how that rating schedule works, that really guides how the DBQ looks. So I've got eight pages of DBQ in front of me. The first page starts out same as every DBQ they're asking for the veteran's information and what role the medical examiner plays to that veteran and what role the medical examiner plays to that veteran. And then the second section on the first page talks about evidence what evidence was reviewed.

Bethanie Spangenberg: 31:58

I always like to take a minute to talk about what evidence should be provided. Evidence specifically for this is you want to show what medications have been used in the last year for treatment of your claimed condition. So if you have a fungal condition and I really lean on fungal conditions because it's probably one of the most common that I've seen as secondary to other things so the skin, the fungal condition, whatever treatment that you're getting for that, you want to show that in your medical records. You want to make sure that that has been outlined, whether it's a prescription history from the pharmacy, whether it's your treatment records directly. You definitely want to have that in the file. You also want to talk about.

J Basser: 32:56

You also want to talk about.

Bethanie Spangenberg: 33:01

Want to try that again.

J Basser: 33:05

Focor Menazal Beta Metastone Cream.

Bethanie Spangenberg: 33:22

Oh shoot to say that word.

Bethanie Spangenberg: 33:32

You also want to submit your own pictures because who knows when you're going to get called for this DBQ and you might be having a great day. The day you show up to your DBQ and your skin condition is perfectly controlled, it is when you have those flare-ups and when those flare-ups are at its worst you need, you must take pictures to document, date those pictures, submit those pictures. I have used those pictures during a DBQ because and I put like free text sticks there's actually not a spot to really talk about that in the questionnaire, but I say you know the veterans submitted pictures from this date demonstrating lesions or areas of the skin and like describe the skin and how much of it is cut, like percentage of the body is covered. Because those pictures tell a story and you want to make sure that the VA has that information and even you can even bring them with you to your GBQ, to that exam, so that way that's part of your story and you can tell the examiner. You know, look, I've already submitted these pictures. I just wanted to bring them to you because you know, of course today I would be having a, an okay day, but I want you to see what this condition does on a regular basis. So that's part of the evidence that I think that you should have in there.

Bethanie Spangenberg: 34:54

Page two it talks about the diagnosis and the very first question. I always emphasize how important it is to have a current diagnosis. The first question is does a veteran have a current skin condition? And you can say the medical examiner can say yes or they can say no, so you want to make sure that that diagnosis is in your file. What's also interesting is sometimes you know, I'm not a dermatologist, dermatology is not my area of expertise. Sometimes, when a skin condition presents to the primary care clinic, sometimes I can look at and say, well, I think this is what it might be, so we're going to try this. And then I'm going to refer you to the dermatologist. Well, a lot of these general examiners that they're sending the veterans to it's the same thing. That's not our area expertise. So we can look at the veteran and say I don't know what that is and I have no way of knowing. You need to go to the dermatologist. Now, sometimes when you go to the dermatologist, they have to get a biopsy of that skin condition to really understand what is going on. I've had patients where they thought it was psoriasis and they go to the dermatologist. They get a biopsy done and it's some other crazy skin condition and it's not psoriasis. You talk about it with your primary care doctor. But if they're not sure you know, ask to see the dermat path and the effectiveness of treatment, because if I put hydrocortisone cream on a fungal infection it will never go away. I have to put an antifungal cream on a fungus infection to make it go away, so that's important.

Bethanie Spangenberg: 37:22

In the diagnosis section we talked briefly about the dermatitis, the eczema and the fungal infections, which are covered under the general rating formula. The other two conditions I wanted to touch base on, because they are so common, are acne and chloracne, and those are outlined in the diagnosis section on page two. Further down in page two is the medical history. The medical examiner is just to tell your story in that area. One of the questions in there specifically asks about any resolved skin condition. Did the veteran previously have a skin condition that is now completely resolved and no longer requires treatment of any type? And we could say this about Ray's toenails Ray, you had your toenails removed. You no longer have the nail infection. We can say that it is currently resolved. It is completely resolved and no longer requires treatment of any type. But you have a history of it, you have pictures of it, you wrote it in your statement and we're going to document that for possible compensation and that fungal infection is likely to recur again because you're diabetic. So you want to make sure that's also, you know, discussed.

Bethanie Spangenberg: 38:34

If we look at page three, all of page three and most of page four is asking specifically the type of treatment, the route of treatment and the duration of treatment, because we talked about how the rating schedule bases all of that stuff to give you disability percentage.

Bethanie Spangenberg: 38:55

The provider goes down each category of treatment and addresses each question related to the rating schedule. If we go to page four, at the bottom of page four, that's where the medical examiner does their exam and this is where the provider has to do an inspection and document the condition and indicate what percentage, approximately how much of the body or the exposed area, has been affected by the skin condition. Now I want to take a minute too to also talk about the physical exam, because, let's say, you're a veteran and you're service connected for genital herpes and you're trying to get a disability percentage because you're on daily antiviral medication for control of your genital herpes condition and you have a DBQ coming up. You have a comp and pen coming up and you're getting really anxious about going. You can go and you can decline the physical exam Because, based off your history, you're already demonstrating that you're on antiviral medication every day.

Bethanie Spangenberg: 40:17

They already have enough to rate you based off your medical history. That medical exam is not ever going to be 40% or more of the whole body, ever going to be 40% or more of the whole body. That medical condition will never be 40% of the exposed body. But you show up. So then that way they don't deny you because you failed to report, but you show up and you decline the exam if you're not comfortable because the evidence is in the file. I've had cases like that and I want the veteran to know that if you decline the exam, that medical examiner should professionally accept your answer, document the answer and move on. Understood answer and move on.

Ray Cobb: 41:13

Understood, yeah, so that puts it back on him. Now, does that go back? Does the medical examiner then look at?

Bethanie Spangenberg: 41:24

your medical records, or does that go back to the adjudicator? The medical examiner should always look at the records because they have to report or document the history and treatment, but that's something that the rater should also be looking at as well. You still want to show up, but you don't have to participate as far as showing an area that you're not comfortable with, especially when the evidence is already in the file, to give you a rating.

J Basser: 41:54

Right. They should understand that already and not even put you in that situation.

Bethanie Spangenberg: 42:02

You would be surprised.

Ad: 42:05

When.

Bethanie Spangenberg: 42:05

I was in there as a C&P examiner. They required us to do for erectile dysfunction for a period of time. They required us to do examinations and I'm like why there's there's truly no exam for erectile dysfunction? Why am I doing this exam? This is completely unprofessional. Why might it?

Bethanie Spangenberg: 42:26

well, you have to, well, you have to, and they got so much pushback on it that they decided they created a box in the DBQ where it says individual declined or examination not pertinent to the condition. So they changed it because of all that pushback that they got.

J Basser: 42:46

Well, it's not history, it's a little part one.

Bethanie Spangenberg: 42:53

And that's similar to this. Now, let's say somebody does I mean herpes anywhere, even on the face or any other body part. The timing has to be appropriate to even appreciate a sore associated with that condition. A sore associated with that condition. So just because they schedule a DBQ, you know, let's say, I show up tomorrow for a DBQ, I'm not going to have a cold sore on my mouth tomorrow, so you have to take I mean, for that instance, you take a picture to demonstrate, if you're not on regular medication, but most of the time, what I find, both clinically and when it comes to VA disability, that if a veteran does have any type of stressor at home, then they elect to use antiviral medication on a regular basis to prevent any type of viral outbreak, prevent any type of viral outbreak.

J Basser: 43:53

So part of One of the major players is, I'm sorry, ray.

Bethanie Spangenberg: 43:58

No, go ahead, I was going to move on.

J Basser: 44:00

We've got a lot of vest-taking guardians and we have a lot of veterans getting some fungal infections down south and one of our buddies had about killed him and they slayed him like a fish because of that. I guess it's a what was that condition called Ray? Was that foreigners gangrene, what it was?

Ray Cobb: 44:20

Right, right. And I mean they actually claimed and told him that if they waited 10 more minutes before they did the surgery, that they wouldn't have been able to save him. It was that close, yeah.

J Basser: 44:37

So that and you younger guys out there, if you ever go and your wife talks you into going to see the doc and getting a skip treatment for a vasectomy, make sure that you walk out of there with a prescription for some type of medication, because that's another issue that brings on those infections. You know that.

Bethanie Spangenberg: 44:58

Yes, any type of stress, whether it's physical, emotional, I mean even unperceived stress. If you change your diet, if you go from a regular diet to a keto diet, that's still stress on the body and people can get outbreaks or viral infections from that. So part of the physical exam, at the very last section it says does the veteran have a skin condition currently without any visible characteristic lesions? At the time of the exam and they can mark that they do have a skin condition without any visible characteristic lesions and that would put you at a zero if you don't take medications. So you want to make sure again that you're providing your own picture. So I just want to reemphasize that Section five is for specific skin conditions.

Bethanie Spangenberg: 45:55

I had talked about the rating schedule defining specific ratings for certain skin conditions such as acne and chloracne, and the rest of page 5, all of page 6, and even into page 7, is specific questions about each specific kind of condition. So if we run through the first example, we're looking at acne and the medical examiner is supposed to document if the acne is superficial and if it's superficial, that's a 0% disability rating. If the acne is deep acne but it affects less than 40% of the face and neck, that is 10%. If it affects 40% or more of the face and neck, that's 30%. And if it affects body areas other than the face and neck, that's 10%. So if you have acne on the back, that is going to be a 10% disability rating. If you have acne on the back.

J Basser: 47:01

that is going to be a 10% disability rating If you have an acne cyst moved in service.

Bethanie Spangenberg: 47:06

You have it cut out, then that would be service-connectable.

J Basser: 47:11

Say that again If you had an acne cyst cut out in service, then that would be service-connectable if they operated on you in the service. What kind of cyst. It was acne. Basically, it was on the temple.

Bethanie Spangenberg: 47:25

They cut it out. So that would be. It'd be more probably compensable for a facial scar, mm-hmm. So Wow. Now when we look at chloracne, we know that. So we understand acne because typically we see it when we're in our younger years. We've seen acne flare up with helmets or face straps or other skin irritation.

Bethanie Spangenberg: 47:55

Chloracne is a little bit different. So chloracne is a little bit different, predominantly in its appearance. When we look at chloracne, what is predominant is the blackheads, or the comedones is what we call them. So it looks a little bit different in appearance and it's specifically related to dioxin exposures and that's how we've connected it to Agent Orange and other dioxins. Is that predominance of the chloracne? Those two go hand in hand. When we look at the rating, it's actually very similar to acne. If the chloracne is superficial, it's 0%. If it affects less than 40% of the face, it's 10%. If it affects 40% or more of the face and neck, it's 30%. Now what changes is? If there is core acne in the skin folds, such as the armpit, the groin under the breasts or between the fingers, that is a 20% disability rating, and if it's anywhere else on the body, it's a 10% rating. So, continuing through five and six. Again, it's specific to the different skin conditions, even the top of seven.

Bethanie Spangenberg: 49:18

The next section, which is in every DBQ, is the tumors and neoplasms. I'm not going to run through those. It talks about specifically skin cancers. The one thing I do want to mention is that the PACT Act made melanoma presumptive. So I think that's important, that if you're a veteran and you have the burn pit exposure and you qualify for that PAC-DEC presumption definitely need to keep that in mind.

Bethanie Spangenberg: 49:45

And then page eight, the last page, is scarring and disfigurement, which we talked about last month. It's just a reminder to that medical examiner that hey, if any of these skin conditions fall into the scar and disfigurement category, you also need to complete that DBQ to appropriately give the veteran that rating. A section for other pertinent physical findings, a section for functional impact and then an open section for remarks and that gets you through the DBQ. Then an open section for remarks and that gets you through the DBQ. Now, depending on how many skin conditions a veteran has, a face-to-face examination is needed for the skin condition DBQ and the time that the veteran is actually in the office can range from 20 to 40 minutes to complete this DBQ.

J Basser: 50:43

And that's the skin, dbq. Okay, now step back and take a deep breath and breathe a little bit. There you go.

Bethanie Spangenberg: 50:52

You've got to get ahead of yourself. That's a lot of information and I knew it was going to be tight because it's 7.51.

J Basser: 50:59

You got it, didn't you? You smoked it, girl. You got it, didn't you? You smoked it, girl, you got it.

Bethanie Spangenberg: 51:05

Lots of info but, I think even just the conversations about talking about what you guys have seen and experienced. I think that's very valuable. And then, ray, you've got the chloracne, correct?

Ray Cobb: 51:21

No, you've got the chloracne, correct?

J Basser: 51:23

No.

Bethanie Spangenberg: 51:23

No, I do not have it.

J Basser: 51:24

No, so is that James? James has it. James has it.

Ray Cobb: 51:26

Yes. So he would have been the perfect person to have.

J Basser: 51:32

Yeah, very, very. I mean he's heavy exposed. He's probably one of the heaviest people that has ever been exposed to it, because he actually sprayed it, didn't know what it was.

Ray Cobb: 51:44

I love his story that he tells. Well, he used to be Fort Gordon. He would go back into a little. He was a game warden. He'd go back into the game warden's hut, his little office, and if anybody's ever been in southern Georgia you know that mosquitoes are very bad there in the summer and especially. And he had his little hand pump bug sprayer and he'd sit there. The mosquito would come by and he'd spray it and watch it fall down. Little did he know what he was doing was spraying it on himself as well.

J Basser: 52:23

Wow.

Ray Cobb: 52:25

He said they'd fall down like a dive bomber, you know.

J Basser: 52:36

Skin conditions. There's so many conditions of skin and the body that it's kind of unbelievable what happens to a vet, especially in service. You don't have to be combat related. It could be anything. The military is like a big mass industrial complex.

Ray Cobb: 52:55

People do get hurt and injured and exposed and everything I guess I think Bethany made an excellent point tonight that we need to educate ourselves.

Ray Cobb: 53:08

For example, you know I'm up to an R2, and even though my toe was treated, the nail has been removed at least twice, maybe three times, cream's been put on it. I've taken an oral pill for it, but little did I know that that might have been a claim years ago that I could have used. I haven't had a problem in the last five years but prior to that. You know I hate to say this, but the VA doctors are not going to tell you that this is a condition that you can file a claim on. I have never had a doctor to tell me that of any of my conditions, it's either another veteran's told me I've listened to a show like this or you know that's the way that I read something, heard something. So you know, guys and gals out there, you know you've got to. It's your responsibility to look at what your conditions and what your medical situations are and determines whether or not you may have a claim for it. If you do, then proceed with it.

Ray Cobb: 54:22

I think your education is economic to me.

J Basser: 54:26

I was with Michael Palmer at the headbark back in 2020, when COVID was going on. They checked my feet out and I said to a young lady I had a. My right big toe was bad. I had a bad fungal infection. She checked me out. She said you're pretty good. I need to go see podiatry. She said podiatry won't see you. They're not servicing for your feet. I said, okay, I come home, made a phone call Over here across town. I went into the Lexington podiatry and modeling center. All the doctors looked like number 10 models. I went back and sat down and she said that's got to come off. She took it off and then they did laser treatments on it. You ever seen that Laser therapy on it?

J Basser: 55:17

After all the soaking and that, yeah, after soaking and that's the salt and all that crap and things like that, it grew back after almost what. Eight, nine months Went back to check it out again. She said, oh, it's got to come off again. The thing's been off three times.

Bethanie Spangenberg: 55:33

Wow. Another thing I'd like to mention, since we're on the topic, is even especially with being diabetic, like anything that involves your feet, you need to heavily document and be mindful of, because even those toenail removals, if you get an infection from that toenail removal, you can lose your toe, lose your toe. So you just have to be, both medically and even on the claim side, just be mindful, check your feet every day and ask questions when you go to the doctor, like is this somehow related to my diabetes?

Bethanie Spangenberg: 56:10

And from a primary care standpoint. We are programmed to consider, you know, to look at the differences in our feet, but most because of the time crunch, most examiners, primary care providers, don't look at their feet of their patients.

Ray Cobb: 56:34

You're right, they don't so right, they don't.

J Basser: 56:43

No, you know at that point you're a person you know. Back in early days, right, va doctors had somebody with them and they would go in and they would dictate what they were going to do and they would examine you. Now you're going to sit in front of the computer just typing away, you know, and they might take 30 seconds and look at you.

Ray Cobb: 57:01

Yeah, or don't even look at you, you just talk and they write it all down, yeah.

J Basser: 57:06

Yeah.

Ray Cobb: 57:08

You know Bethany pointed out another thing about the AFOs that will also qualify you for caregiver one. What's that? I went to the AFOs. Well, I had AFOs. If you don't get those things on correctly, they cause blisters and I ended up having to have the skin graft, and so that's what got me the R1 under the caregiver one, because the caregiver one program is about if you have to have braces, assistive putting them on and adjusting. That is one of the criteria that qualifies you for level one. So you know, keep that in mind. And once again, we're talking about the diabetes of the feet.

J Basser: 57:56

If you do that, you're going to breakfast at IHOP, right? What's your closest IHOP at?

Bethanie Spangenberg: 58:00

Oh gosh, If you do that, you're going to breakfast at IHOP, right? What's your closest IHOP?

Ray Cobb: 58:05

at Gosh. I've been to a few IHOPs, yeah.

J Basser: 58:16

All right, folks. We've got a minute and a half left. Betsy, why don't you go ahead and give the information about Valor for Vet and the phone number to contact information, if you would?

Bethanie Spangenberg: 58:28

Our website is wwwvalor4vetcom. Our phone number is 888-448-1011. Give us a call. We have veterans waiting to talk with you about any questions you may have about our services.

J Basser: 58:50

Good job, guys, good job.

Bethanie Spangenberg: 58:54

Thank you for having me. I appreciate you allowing me to speak about all this medical nonsense.

J Basser: 59:02

It's not nonsense.

Ad: 59:03

I mean I'm sorry to say.

J Basser: 59:06

No, no, it's actually a comparative of people learn it. What's wrong with you? So no, as a matter of fact, you're a good start to Taylor Chase. This is the last time I saw all of you. How many hundred DBQs. Anyhow, y'all, I'm going to go put a plug on it To the next week, guys, we'll have another guest on, we'll do another show. Well, thanks, bethany, for coming on and giving us some good information.

J Basser: 59:33

Thanks, ray, for coming in while he's on his vacation and we'll be signing off. For now. You have been listening to the Exposed Vet Podcast. Any opinions expressed on the show are the opinions of the guest speakers and not necessarily the opinions of Exposed Vet, exposedvetcom or Blog Talk Radio. Tune in next week for another episode of the Exposed Vet Podcast. Thanks for listening. Hey guys, we'll all be here.

Ray Cobb: 1:00:03

Okay, All right, that's good, Anthony. I told a gentleman from Chattanooga to reach out to you. I don't know if he has yet. I told him to refer my name to you. He needs a little bit of work and some verification. But I also told him that before he did anything he needed to try to find his medical records from being in the service. But if a gentleman from Chattanooga, Tennessee, reaches out and gives you my name, then he's legit. I did talk with him.

Bethanie Spangenberg: 1:00:37

Do you have a name?

Ray Cobb: 1:00:39

I don't with me now. I do at home. I have it written down at home but I'll get it to you. I'm hoping he's taking the time now because his right hand is a 10% disability. He was in the Navy in asbestos exposure but he hasn't gotten anyone to say that, so he doesn't have anyone to say that so he doesn't have the diagnosis for it yet. Oh, he's going to have to. Is that the guy I talked to, though?

J Basser: 1:01:11

I'm not for sure. I told him he needed to get a high-resolution CAT scan, HRCT. Yeah, yeah, yeah. That was probably him, because I told him the same thing. Everything else would be a biopsy.

Ray Cobb: 1:01:28

Well yeah, or a watch, yeah.

J Basser: 1:01:35

And without that he hadn't got a chance to win an acclaim. Well, he had to wait for it. He had a lot of problems with it. He had a lot of problems with it you know Right, this is like.

Ray Cobb: 1:01:43

He's trying to say he was exposed while in the Navy.

Ad: 1:01:47

But as I questioned him, I had a little bit.

Ray Cobb: 1:01:49

I said well, did you work? You know, did you have to help remove asbestos from any ship? No, but it was all around me. Well, okay, that's when I got interviewed by the Packback people.

J Basser: 1:02:04

They're like tell me how you were exposed to asbestos. I said, well, I ripped it out on more ships of submarine.

Ad: 1:02:11

Okay.

J Basser: 1:02:11

Now, how were you exposed to radiation? I said, well, I was removing asbestos on more submarines inside the reactor compartments, yep.

Bethanie Spangenberg: 1:02:18

Hey, john, that necklace. I tried to look it up and I couldn't find that radiation necklace that you were telling me about. Can you send me the name of that again? The?

J Basser: 1:02:33

other one.

Bethanie Spangenberg: 1:02:35

Well, you were saying about the genie bottle right.

J Basser: 1:02:36

Yeah, the genie bottle yeah.

Bethanie Spangenberg: 1:02:37

TLD. Okay, you were saying about.

J Basser: 1:02:40

You're talking about the TLD, the genie bottle, right, yeah, the genie bottle. Tld, yeah, tld, yeah. Okay, let me look it up and see where they're at, okay.

Ray Cobb: 1:02:47

I tried to find one.

J Basser: 1:02:50

Well, I looked and I couldn't find so Okay.

Ad: 1:02:55

Well, I know they're all in the vintage.

J Basser: 1:02:58

Okay, the vintage. I think they're still in use. They were the cat's meow. Back in the 80s Everybody had them. A dual crystal, I couldn't find anything. Let me dig, I can't find something.

Ad: 1:03:19

Okay.

J Basser: 1:03:20

They've got to be around somewhere.

Bethanie Spangenberg: 1:03:24

See, everything I find is a device, but he's restricted on what he can have. So if they have the necklace thing you were talking about, that would be cool.

J Basser: 1:03:35

All right, well, I'll look it up, we'll find it. I'll send you some information on it anyways.

Ad: 1:03:41

Okay.

J Basser: 1:03:42

Or you can get it, because I'm pretty sure they still got them. They got to have. Matter of fact, my wife was working in government. She was temporary over to the reading place. They read them here in Kentucky and that's all she did was plug them in. You know they did the readings with both crystals and a's. All she did was plug them into the. You know they did the readings with both crystals and a couple times she read the bottom crystal and that's pretty serious. People died. They don't advertise that stuff, do they?

Bethanie Spangenberg: 1:04:09

They don't. And there's actually, they're doing a lunch and learn. There's an attorney firm here. Well, I said locally, it's probably somewhere in like Tri-State area here, locally. Well, I said locally, it's probably somewhere in like tri-state area that's doing a lunch and learn on the uranium enrichment plant here. And so I was going to sit and do it, because I did not realize until about two weeks ago that there is specific reference to this Portsmouth plant or Piketon plant here in Ohio in the 38 CFR.

J Basser: 1:04:43

Right.

Bethanie Spangenberg: 1:04:45

I had no idea Also.

J Basser: 1:04:47

the gaseous diffusion plant for Dukes of Kentucky is also listed. Oak Ridge, tennessee. Yeah.

Bethanie Spangenberg: 1:04:56

Yeah, Oak Ridge.

J Basser: 1:04:58

Yeah, All right. Well, I will find that for you. I know it exists, so I mean, matter of fact, I've got an old one in my drawer that I kept you know. Still, I'll find it for you.

Bethanie Spangenberg: 1:05:11

Let me know like what it looks like or what words I need to look for Something.

J Basser: 1:05:16

TLD. Basically it's a TLD T as in.

Bethanie Spangenberg: 1:05:21

I don't know.

J Basser: 1:05:25

Tango Leroy David.

Bethanie Spangenberg: 1:05:28

Okay, yeah, tld.

J Basser: 1:05:36

Dosimeter, some old luminescent December. That's the changing a little bit. It's not the GE bottle, but the same thing that changed the design a little bit. Calcium fluoride it's got a clip on it hanging around your neck.

Bethanie Spangenberg: 1:06:08

I'll do some digging now that I know specifically what I'm looking for I'll send you the link to it, okay okay, sounds good okay, let's see here Sounds good.

J Basser: 1:06:25

Okay, this is the newer version. There's more.

Ray Cobb: 1:06:38

Hmm, it's a little technology, hey guys, we'll catch up with you later. I've got to go and win a little money tonight. I need some spending money.

J Basser: 1:06:47

Yeah, you're on vacation, don't be falling over here, I am on vacation, don't be falling off the tunnel. Hear me.

Ray Cobb: 1:06:54

Don't be falling off the tunnel. My fingers soar from pushing that button that says spin, spin, spin.

J Basser: 1:07:03

Good luck, buddy.

Bethanie Spangenberg: 1:07:05

Have fun.

Ray Cobb: 1:07:06

We will. We'll catch up with you guys later. Enjoyed it, bye.

J Basser: 1:07:13

Let me dig this thing up, beth. I'll give you several things. That's you guys too. Okay, sounds good, all right, and that's you guys too. Okay, sounds good. All right, we'll catch you later. Give me a holler or shout or message or call or whatever.

Bethanie Spangenberg: 1:07:27

All right, sounds good.

J Basser: 1:07:29

Have fun with the kids All right, bye, yes, bye, bye.

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