SPEAKER_01: 0:10

The year's about gone. I'm a co-host today, Mr. Ray Cobb. How are you doing, Ray?

SPEAKER_00: 0:17

Trying to stay warm down here in Tennessee. It's cold.

SPEAKER_01: 0:20

It's cold here too, but I tell you, I've been coaching all day long. But I want to tell our veterans now the next check you get Uncle Trigger's gonna give you a little bit of a raise. I need to catch us up with the manufacturing economy because it's run all the week on our little backside. Anyhow. Today we've got Bethany Spencer. She's the owner of Bowler for Vet. She is an accredited appeals agent. So she's a former VAC and P examiner, and uh she doesn't practice VA appeals right now, but she might change that eventually. Anyhow, we're gonna discuss secondaries and aggravation, and I want to turn it over to Bethany.

SPEAKER_04: 1:08

I saw that um that Medal of Honor recipient. That's a big, that's a big raise. Oh my goodness.

SPEAKER_01: 1:15

Well they they should have got one, but they need one for a long time, you know. I mean, it's I mean, I don't think you got enough to sell some guys who deserve more than what they got.

SPEAKER_04: 1:24

Was it like 61,000 or something wild like that?

SPEAKER_01: 1:27

It's like fifty eight hundred a month.

SPEAKER_04: 1:31

Yeah, uh it's it's I'm glad to see it. I was excited to see that come through. But thank you for having me. Yeah, I agree. Uh thank you for having me. Um, tonight we're gonna talk about secondary and aggravation opinions. We have been busy running around um trying to keep our our heads on our shoulders with all the craziness the VA puts out and some of their denials, and we'll talk about those cases as well tonight. Um I'm gonna start with a quick overview of a little bit about what we talked about the last time, only because I want to make sure that we let's see if I can get it to move here. Not leaving them hanging too dry here. But so for tonight, what we're gonna talk about is uh just a quick overview of the medical opinions and what they are and what role they play. If you want to watch the full episode, there's a link there for the full episode. You can scan the QR code, and that's our last one hour long um video session that we did, and it'll give you the in-depth details for just about a medical opinion in general. We're also gonna talk about secondary conditions, aggravated conditions, and how to service connect those. I'm gonna give you a link to one of our helpful tools for veterans seeking secondary and aggravation service connections, and then we're gonna talk about cases. So I always like to talk about cases, but I talk too much and we don't always get to them. So I'm really gonna try to leave some time for those cases for us to talk about them tonight. And I'll sit down so I don't continue to sway. All right. So a medical opinion for VA disability is a written professional opinion by a qualified healthcare provider that addresses whether a veteran's current medical condition is related to an in-service event, injury, illness, or other another service connected condition. An independent medical opinion is a medical opinion for VA disability claims that is written by a non-VA qualified health care provider that addresses whether a veteran's current medical condition is related to an in-service event illness or injury or another service connected condition. Now, I bring these up because I want you to understand there's a lot of terms that are referenced when we talk about IMOs, nexus letters, medical opinions, and we use them interchangeably. So I think it's important that when veterans see these words, they need to understand that we are talking about the same thing. Okay. The purpose of the medical opinion is to confirm or rule out whether a medical condition is related to military service or to another related condition. Medical opinions are performed by both VA, C and P examiners, compensation and pension examiners. They're also done by non-VA clinicians. The Nexus letter falls into step three of the VA process. It is designated as gathering of evidence from the VA's portion. And this um pic this picture comes from the VA directly. This is where they put the CNP exams. Again, here is the QR code and the link if you want to watch the full episode, get an in-depth discussion and understanding of medical opinions. All right, anything you guys want to add before we move into secondary conditions? All right. So, secondary, what is a secondary condition? A secondary condition is a disability that is directly due to or the result of another service connected condition. And an example here that I'm providing is that an ankle can ankle condition can develop secondary to a veteran service connected flat foot condition. And we're gonna walk through this and take a look at some clinical things so that way you understand the relationship, because this is a common claim, common secondary condition. And I think it's important for you guys to understand what we're looking at from the clinical side. It's important to note that secondary conditions, if they are granted, they are rated the same as direct service connections. There is no change there as far as compensation goes. So if we look at this picture of the foot here, we can see the tendons, the bone, the ankle joint, the toes, and the fat pad. So the yellow there is the fat pad. Um, this is what a normal arch is supposed to look like. Okay. So when we look at the foot, and we're talking about Pesplanus, it is in fact the underside or the arch there that we are looking at or assessing. If we look from the back, so this would be the patient's left foot. Um the fibula, I can't really point. Let me see if I can point. There we go. This fibula right here is going to be on the outside. Okay, so we're looking at the left foot here. And what we're trying to look at from a clinical standpoint is how the ankle and foot are aligned. So when we compare a normal arch to a flat foot or pesplanus, you can see that the arch is much different. Okay, we see that it's flatter, but we also see that all of these structures have changed. Okay, we can see the collapse of these bones here, these joints have opened up, and you can see that the um the pressure on the toe has changed as well. Now, when we look at flat feet in comparison to the normal arch from the back, okay, again, this is the oh the fibula is the outside. There we go. So the fibula is the outside here. When the arch collapses, you're changing the structure of the bones, and you're actually changing the stressors upon the ankle here. So this square portion that I'm outlining here is called the ankle mortise. Okay, so those structures, the stressors on those structures change when you have pes planus. So this picture here is giving a more realistic visual of an individual with bilateral pes planus and what they look like inside their shoe. So we can see here that the arches are collapsed. Okay. On the insides here, arches are collapsed. And we can see the structural change upon the bones. It's no longer a square, square ankle anymore. Okay. So when we look at the x-ray, you look at it as if you're looking at the patient when you look at x-rays. So this is still the left ankle. Again, I'm going to highlight this ankle mortise. So this is a normal ankle mortise. There's nice and healthy gap there. That's going to be your cartilage that supports the gliding of that joint and the movement between the bones. And then we compare it to an arthritic ankle mortise. So when the arch of the foot collapses and it changes the stressors upon the ankle, you can start to see the wear and tear. So you don't have that good, healthy space around the ankle mortise anymore. Okay. And this is something that develops depending on the severity of the flat foot, depending on what type of treatment you get for the flat foot. And it also progresses obviously with age. So there's a lot that that plays a role into the arthritis development. So you can see in these images that they depict how a Pezplanus condition can cause ankle arthritis. Any questions when we're talking about relationships for secondary conditions?

SPEAKER_01: 9:56

Would that be a secondary just to a condition like diabetes?

SPEAKER_04: 10:00

Yes. So it's not just joints, it's also other diseases. Um we can look at all kinds of diseases that cause or contribute to sleep apnea, thyroid, diabetes, PTSD. You know, we talk about that a lot. That's a big one that we see in a lot of our veterans that they're claiming sleep apnea is secondary. And I want to take a minute to talk about sleep apnea and it being a secondary condition. Statistics show that sleep changes in the active military are present. Okay. So a lot of veterans try to tie their sleep apnea direct to service because of the clinical awareness, okay, just in general, medicine and its awareness of sleep apnea. It did not become prominent until I would say around um 2005, pushing into 2015, that time frame, it really became something to be aware of, also involving the Department of Transportation and truck drivers and them having accidents behind the wheel when it comes to sleep apnea. So if you're a veteran that served during Vietnam or Gulf War, and you're really trying to get it direct to service, your chances are better to get it as secondary. That is because symptoms of sleep issues are common during service, but a getting or capturing a diagnosis of sleep apnea within a reasonable time frame for those era veterans is very unlikely. Okay, you probably did not have a sleep study in the 1980s. You probably did not have a sleep study in the 1990s. So it is in more successful for the veteran to look at secondary conditions when it comes to sleep apnea.

SPEAKER_00: 12:03

For sleep apnea, what would be one of the secondary conditions from the diabetes or from heart or what?

SPEAKER_04: 12:11

So we tend to look at each case individually, obviously, um, but we like to stack them on. So if there's a veteran that has PTSD and tinnitus and diabetes, we're gonna take all three of those elements and put that into a nexus letter that may have caused or most at least as likely as not caused a sleep apnea. So we're gonna try to look at all the risk factors for sleep apnea development and throw them into that nexus letter. Does that answer your question?

SPEAKER_00: 12:44

Yes, yes, definitely.

SPEAKER_01: 12:46

Say, for example, um you had spinal injury and you got a paralyzed phrenic nerve for one of your diaphragms, so your lung doesn't move up and down, you know, on a regular basis. That would be a cause for sleep happening right there.

SPEAKER_04: 13:03

John, we're gonna have to do that uh social media trend, the whole put a finger down if you have a uh paralyzed diaphragm and you've to raise your hand on that one. Uh but yes, absolutely. Paralyzed diaphragm, asthma, COPD. Uh, there's there's so many things that contribute to sleep apnea. And even I actually have one pulled up on my computer here. Let me look at the date on this. This is one we wrote back in September. Um, a lot of the cases, I mean, we've been doing this for over 10 years now. We just had our 10-year anniversary at Valorvet. So we've been doing this for over 10 years. So a lot of the cases I talk about today are stuff that's more recent just because the VA patterns have changed and the way the VA responds and denies and all that other good stuff, it's changed. So I want something that's relevant for you know listeners. But this particular case came to us in September, and we were able to write a nexus saying that his sleep apnea is secondary to the service-connected condition of left total knee replacement, uh, lumbar, lumbosacral strain, bilateral hip strain. And we took those, those three major, actually, it's four if you do bilateral hip. So we took those four major joint conditions, and we said that those conditions cause the veteran to become obese. Okay. And then we were able to tie it secondary through an intermediate step. So we're not talking about obesity as an intermediate step today, but the way that Nexus letter um was written is we take all the contributing factors that we know the veteran is service connected for, and we talk about how those conditions contribute to the development of sleep apnea. Because there's not just one thing. We didn't say, I mean, medicine is not like, okay, this is the one thing that causes sleep apnea. We know that's not the case. From clinical practice, there's hundreds of things that contribute to sleep apnea. And so we really have to um use a clinical thought process whenever we're writing Nexus letters, and the VA examiner should be too. They shouldn't be looking at one condition causing the veteran's secondary claim. They need to look at it as a collective.

SPEAKER_01: 15:23

Let me speak directors to the vets real quick. It's listen, show. Guys, if you were in service and you gained weight in service, say you went in at 140 pounds, time you got at you was 200 pounds. If you did that, especially back in the 80s and 90s. Okay, they're gonna track you because they do. And you have to prove that you gain weight in service for other conditions. So the best thing you can do is get in your records, find your enlisted performance evaluations, find every one of them, or several of them, and one for each year. And go run it back and reach, it'll tell you exactly what your weight problem was and what your BMI was at the time of that performance evaluation. There's your dead reckoning proof that you gain weight in service.

SPEAKER_04: 16:11

Yeah, and from a medical expert standpoint, for those cases, what we do is we talk about, you know, obviously we look at everything that particular veteran has, but for a case like that, we're gonna say clinically their symptoms are consistent with a sleep apnea condition that started in service because the strongest risk factor is weight gain and they gained weight in service, and they were symptomatic in service. And so if their story is clinically consistent with their weight gain causing their sleep apnea in service, then we will tie it direct. It's only those where it's like, oh, well, I had a normal weight when I when I got out, and then I still had these sleeping issues, and then for some reason these sleep issues were so bad, but you didn't get a diagnosis until 30 years later. We got to look at what what was present at the time of diagnosis for those cases.

SPEAKER_01: 17:09

Usually this information is on the second page of that form. And I've seen so many times where they'll pop sheet a form and give the information on the first page. Don't even look at the second page. They don't find the gravy. They just they just found the stuff in front, which is you know, more or less, you know uh what kind of saber you were and things like that. It didn't go into detail. The back page goes into detail. Not just that, it also tells what job you did. Yeah, I've one so many best claims doing this for people.

SPEAKER_04: 17:44

The other thing I want to mention while we're on secondary cases is um we get some of them, we don't get a lot of them, and I think mainly it's because veterans don't understand what has happened or what what how they can service connect this, but you can get secondary conditions um if you would fall or get injured because of another service connected condition. So recently I talked to a veteran who um during service they had a really bad right ankle condition and they almost lost their leg. So they had three surgeries due to infection and service, and now they currently, you know, he's 62. He's currently having a lot of vascular issues, a lot of muscle wasting in that right leg. Well, just in July, he fell because his his right leg was no good and he broke his left leg. And all throughout his records, you see these chronic issues with his right leg. And then when he presents to the ER, his story is yeah, I I tripped because my right leg was giving me issues and it caused me to fall. And then he was treated for this left leg fracture. Um, and I'm like, you need to file for that because you fell because your right leg causes walking issues, it's documented all throughout your health record. You are eligible for a secondary service connection for the left leg fracture and any surgeries or any complications that come up from that left leg fracture, and that's an that's you get a full rating for secondary conditions. So, you know, we filed for it. Well, he filed for it with my recommendation, but I haven't heard anything back. But even the attorneys, when we go to these conferences, the attorneys talk about file for any head injuries that occur from falls and related to service connected conditions. I mean, there's there's so many ways that you can service connect the other conditions, um, but I don't think veterans really understand, you know, if somebody falls or gets injured because of diabetic neuropathy from vertigo, from Um hypotensive episodes or things like that. You can get service connected for secondary conditions.

SPEAKER_00: 20:08

Anthony, uh, I've got a question for you. I had a gentleman this past week contacted me, and um he has just been recently diagnosed with Alzheimer's. Now, in doing the research concerning Alzheimer's, what um comes up is is a couple of things, of course, uh trauma to the head, uh, then also lack of oxygen to the brain, and then alcoholism. And to come to find out, this gentleman had a triple bypass and um a lot of cartilage in his arteries still today. Well, the the spots that are showing up in his brain now is causing the Alzheimer's. Now, the VA doctor said because of his PTSD, for probably two or three years he self-medicated with alcohol. Now, yes, alcohol, long period of use of alcohol, is known to cause Alzheimer's. However, I'm not for sure two or three years has the problem as much as aesthetic heart disease, which he's been given 100% for. His injection factor is down around the 30 range. And um to me, that sounds like it would be more secondary to it than with the self-medicating, but the self-medicating was caused from his PTSD. Can you connect those? Does that line up, do you think?

SPEAKER_04: 21:47

Yeah, I I want to tell you a story after I explained this. But yes, if the alcohol or any substance abuse was the result of self-medicating for their mental health condition, even smoking, you can get service connection for secondary conditions like Alzheimer's or vascular dementia is another one. Um and even if the veteran, I don't know if he's Vietnam, but if he's service connected for coronary artery disease through agent orange exposure and yes, PTSD, then we would take that nexus and we can compound both. We would say PTSD, alcohol use from PTSD, and um the coronary artery disease all contributed to the Alzheimer's.

SPEAKER_01: 22:41

It used not to be, but now it is.

SPEAKER_00: 22:44

Well, uh uh what we were talking about was trying to get into an R1 on his disability because you know he no longer can he's gotta be told his wife has to mix up his medicines and has to make sure he takes them and everything. I mean, uh sometimes he doesn't even know what day of the week it is. A lot of times.

SPEAKER_01: 23:06

How's his limbs? I mean, is he got function or does he still walk, or is he is you know he tells you?

SPEAKER_00: 23:13

He's just recently in the last six months been given uh a hundred percent for Parkinson.

SPEAKER_03: 23:20

Yeah.

SPEAKER_00: 23:24

So yeah, he has he has some balance problems and yeah. So I think uh yeah, his next step is to try to get uh he's got standard aid in attendance to try to get to an R1. Possibly an R2.

SPEAKER_01: 23:44

Okay. Go ahead, Bethany.

SPEAKER_04: 23:49

In my opinion, I don't think the VA does a good job recogn recognizing cognitive impairments related to veterans and their service connection. Yes, they have long-term care facilities at the VA, they have short-term care facilities, they even have dementia units. But when it comes to actually service connecting them, typically the dependents or the caregivers don't know what to do. The veterans not in a mental state to where they can advocate for themselves. And um, I don't I don't think that the VA rating system in general does a great job in trying to advocate for veterans who have cognitive issues. Um they they really need that advocate.

SPEAKER_01: 24:33

Yeah. They took full advantage of that misinformation, don't they?

SPEAKER_04: 24:38

Yeah, and it's those that need it the most, and that's what's hard because I've watched um, you know, veterans with dementia who don't even know who they are, who don't even they put their right shoe on their left their left foot, or the you know, um they're really struggling, and I I think the VA doesn't pick up on that like they should from a benefit standpoint.

SPEAKER_01: 25:02

Hurry and get that stuff done because people get those. I mean, you go on, you've got stages of this stuff, okay? You get a certain stage, it's over. Yeah, you know, like said it. It's it's it's it's a terminal disease because eventually it will get you.

SPEAKER_00: 25:16

Well, he told me the VA doctor told him he had between four and no more than eight years.

SPEAKER_04: 25:25

Um the story that I wanted to tell you related to the alcohol or substance abuse, is when I was in the compensation and pension clinic, I felt like the environment when it comes to those with substance abuse in the CMP department was that those who used substances were doing so willfully and on their own accord. And so I remember a veteran sitting in front of me, and his wife and him both were saying that his neuropathy was the result of his alcohol abuse. And I just I think, you know, in reflecting, like I absolutely think that was possible or that was the case, but the mentality wasn't to willfully write something like that. I don't think the training was adequate. And so I was really, I really misunderstood, you know, the purpose. I'm like, why are you here trying to get a benefit for something that you're willfully doing? And so um I and that's in you know, hindsight here we're you know, 15 years out from that that situation, but I I distinctly remember that because it it was like, you know, I felt like that somebody was trying to cheat the system. Um but I don't think that even on the comp and pen is examiner side that they're doing enough to educate on on what entitlements the veteran has and really trying to let go of the stigmas associated with substance abuse in veterans.

SPEAKER_01: 27:11

Well, it it happens, and it also leads to things like homelessness and stuff like that. You know, so it's it's pretty sad. And uh and right now, if you're a vet and you're doing drugs and you're doing pills and things like that, every time you look at one, you're risking your life. Because nobody knows how much fentanyl and things like that have been mixed into your drugs and it'll kill you.

SPEAKER_04: 27:38

There was a news, uh, one of the local news channels put out just last week that there is a bad batch of uh pills in Columbus that are laced with fentanyl, and they're seeing multiple deaths from those bad pills. All right, I'm gonna jump into aggravation here. I told you I was gonna get be on uh a more strict timeline here so we can get to these cases today.

SPEAKER_03: 28:18

You got it.

SPEAKER_04: 28:19

All right, so an aggravated condition is a non-service connected disability that was made worse due to service connected condition or due to military service. Often you'll hear beyond the natural progression. So, one example is a veteran's asthma condition was made worse due to their service connected rhinitis condition. And is that uh clinically consistent? That's we see that in the clinic, that if we don't get their rhinitis under control, it can cause asthma flare-ups. And that's, you know, if you think about it, the upper respiratory system drains into the lower respiratory system. And so a lot of those things that aggravate the upper respiratory system can drop down and make the asthma condition worse. So for aggravation aggravated conditions, the rating is based on the degree of worsening. Okay, it's not the standard direct service connection or secondary service connection. It is rated it's rated differently. It's based on, okay, your condition was here and now it's here because it was made worse. And so you get the difference of the two. So for any private medical opinions or I mean even VA opinions, if you are trying to get a service connection for something that the military service aggravated, these service treatment records are required for any clinician trying to write a nexus. Okay. And the reason being is because we have to determine a baseline of the medical condition before it was aggravated, and the level or the degree of severity of the condition after it was aggravated. So if we don't have those service treatment records and you're trying to say, well, it was aggravated by service, we have no way of looking and seeing to be able to say, okay, well, when you started, it was X, Y, and Z. And when you got out, you know, X, Y, and Z. Now, is it required for all of them? No, we can do it based on statements, but I still want to see those service treatment records because I have to go in there and see what your entrance examination looked like. I need to try to pull evidence from any performance reviews like you were talking about earlier. So I need to see those records in order to advocate for the veteran themselves. Another example here for aggravation is a veteran's flat foot flat foot condition. We're going to stick with flat feet today. Um, and if the flat foot condition existed prior to service, we have to show that it was made worse due to their military service. And we get a lot of these requests as well because a lot of veterans actually don't know that they have flat feet when they're going into service, which is you would think it's strange, but they don't. Um, actually, a lot of patients don't realize they have flat feet. So that's not something that you know that we're taught as kids, like, oh, your feet are flat, or you know, you just show up in the middle of the like, oh, you have flat feet, and they're like, Oh, I do. So there's different degrees of being flat footed. So here we see we're gonna say that this flat foot condition here is the veteran upon entry. Okay, they have a mild pes planus that is asymptomatic. They're not having any pain, they're not having any symptoms of the ankle pain, foot pain, nothing. Okay, they don't have any calluses that are consistent with foot deformities or anything like that. So, in this scenario, we look at the rating schedule and we see here at the beginning of service, before the condition was aggravated, it would be considered mild. Okay. So that would be a zero. So then let's say the veteran goes through four or five years of service, and at the end of service, this is what we're looking at. So this is clearly progressed. Okay. We're gonna call this moderate pesplanus that it is symptomatic. Okay, he's having foot pain. So this condition would be rated at a 10%. Here's the two conditions side by side. Okay, we can visually see a difference here. We can see that the arch has collapsed. Okay, we now see the the archway is now impressed upon the floor. We can see some calluses here that are changing. We can see the collapse of the ankle. Okay, we can see like see how sharp it is there compared to the other.

SPEAKER_01: 33:08

We definitely have some foot changes. The whole bottom foot will be a callus on there because it's making full contact with the floor correct. Okay.

SPEAKER_04: 33:20

So when we we look at it, we know the veteran started as mild, the condition was aggravated, causing it to be moderate, and the veteran would be compensated at 10% because the difference is 10%. I want to talk about beyond the natural progression. Okay. So let's say this or look at this scenario here or this figure. If someone at the age of 18 has pesplanus and they are in a sedentary occupation, they're not alert really on their feet, they may have very minimal progression, if any, related to their feet. Okay. If an 18-year-old goes into the Marine Corps, or any type, I would say Marine Corps because my husband was in the Marine Corps. So, but if they do any type of physically demanding activities, they're up on their feet, they're walking on concrete, they're in steel-toed boots, they're in work shoes that don't support their arch, you can actually have a rapid progression. Okay. So when we look at somebody who has pesplanus and they're in the Marine Corps for 20 years, we're like, yeah, yeah, yeah, this is definitely beyond the natural progression progression. You're going to age, you're going to get arthritis much quicker. And so that's really what we're trying to understand from the clinical side. So that's why we when we do aggravation opinions, you know, veterans try to give us a few pages here and there. And it's like, no, we we really need the full picture because we're trying to advocate um, you know, the full story. We really need to understand the progression. Any questions about aggravation?

SPEAKER_01: 35:07

Basically to the extent of the aggravation. So whatever the to whatever extent above the normal progression, I guess that uh they'll pay the difference. Is that correct?

SPEAKER_04: 35:19

We used to see a lot of aggravation opinions. We don't see them. I mean, we still see them, but we're not seeing them as frequently as we used to. Um I'm not really sure why. I mean, that I haven't figured out a rhyme or a reason, but we're just not seeing them as much.

SPEAKER_01: 35:36

That coincide with the with the start of the AMA, in my opinion. During legacy, you know, you see a lot of aggravation issues, but you know, I don't know if people are just not filing them or they don't understand or what, you know. I don't know if you'll see it will be in the, you know, will be in the in the statute. And uh read statutes now, they just go trust their reps or whatever. And people only file the claims that way. A lot of these reps don't have no idea what aggravation is either, you know. It's just people they're just claims meals, they sit you down and write your claim out, send it in.

SPEAKER_04: 36:15

I think you're right about the timeline. But what it do you know or think have any idea of what about the AMA would have uh triggered the decrease?

SPEAKER_01: 36:27

Probably the form, so I haven't seen an aggravation form of you. I mean they're gotta you gotta have a form and the AMA to fill out a form. If you fill out the wrong form, they'll kick it back to you. You fill out the wrong form, put the wrong date on it. Well, you sent it to me, you know.

SPEAKER_04: 36:45

I wanna look at this form and see what it says. Because you're right. The timeline's right, and I'm like I mean, and to be honest, sometimes aggravation opinions may not be worth worth the squeeze, you know, but at the end of the day, when I the other perspective I look at is what if that aggravated condition causes your demise?

SPEAKER_01: 37:15

Well, I don't see, I see a lot of people that are service connected for like heart and valve issues, you know, the structure side of the heart. And then later on they'll develop arteriosclerosis, athosclerosis, you know, corneal heart disease. And but they won't connect it unless you're you know being ombed or whatever, you know, they'll they'll deny the claim. But that will be a good purpose for aggravation because that's going to aggravate your vows anyways. Which should be cut and dry, right? They speak a different alphabet than we do.

SPEAKER_04: 37:52

Um, I had a veteran tell me the other day that they had an inside with the process um for the rate the regional office, and they're saying that a lot of the raiders that they've hired, the new raiders, they are typically, and I know the statistic, but to hear it come from a veteran who has an inside, it it brings more value or weight behind that thought process. But they're hiring younger people who don't have any education in order to basically brainwash them into like their way of thinking rather than being um like independent thinkers or rather than being you know empathetic or yeah.

SPEAKER_01: 38:46

You had and the requirements are still a four-year degree, so if they if they went to college and now they're trying to work with the they've already been brainwashed once. So now they're gonna go in and get again, so they're gonna their brains won't be much by the time they get going.

SPEAKER_00: 38:59

And that way it was back during the Vietnam era. I mean, they went after guys that you know were fresh out of high school, then didn't go to college, didn't, you know, really didn't have a lot of educational background, and and they put them in the army and they brainwashed them. That's that's the way I saw a lot of guys that you know it's kind of scary to be with them because you didn't know if they understood how to fire that M16.

SPEAKER_01: 39:30

That's true, but with the V8 situation, you know, you only got one word, no.

SPEAKER_03: 39:36

You know.

SPEAKER_01: 39:38

That's why they get their employees from interest companies. No and heck no.

SPEAKER_04: 39:45

So I looked at this 526 EZ and there's a dedicated section that discusses secondary conditions, but uh the word aggravation is mentioned one time and it doesn't get its own. section. The word aggravated is in there, but it doesn't get its own section. I might that might be the case.

SPEAKER_01: 40:17

It's going to take an older salt. That's been doing this for a long time. That to understand this. A lot of these new folks coming aboard they're not going to understand this. If you come in post AMA, you're going to train on the AMA. You might look at some legacy stuff, but they're saying, well we're done with legacy. Yeah yeah blah blah blah, whatever, right? Okay. So they need to be completely trained. Especially your VSOs. Uh Lady, like your folks down in Tennessee. They need to understand what aggravation is. And you know, for example right now from what I understand if you have an aid aid attendance issue you're going to the board. Because they're not approving nothing.

SPEAKER_00: 41:02

As a matter of fact, one of the individuals I helped and got denied his A and they say you have to be in the bed uh 16 hours a day in order to get A. I've never I'm I didn't I've never seen that written anywhere.

SPEAKER_04: 41:22

You know what I find interesting? Oh sorry go ahead.

SPEAKER_00: 41:26

The doctor didn't turn it in for him because he said you're not in the bed 16 hours a day and we've been told to get A you have to be in bed be in the bed six to be bed written for 16 hours a day. And I hadn't seen bed written mentioned in A. I have seen it mentioned in in uh R2.

SPEAKER_01: 41:48

It's in there on this situation but they're reading it wrong. It's pathetic way that's a cue if it's written if it's in writing it is a definite error. Because uh that's not that's not what the regulation state you just have to prove a need. So it's what they're doing right now. You know they're making some crazy stupid decisions like that things are going to differ level appeals and uh you know I got a docket number yesterday. And believe it or not I got a docket number for that. Thirty minutes later I got a docket number from the Federal Circuit two different cases in the same date about the same time.

SPEAKER_04: 42:38

Really how how are they gonna do that? One's BVA and one's federal court different issue not the court not the veteran's court the federal circuit US district court I'll be interested to see how the federal circuit does yours.

SPEAKER_00: 43:07

I just wonder if they'll read it's what I I sit here thinking I can't wait to see that one.

SPEAKER_01: 43:14

Well I got news for you I will be going to that one how far out is that do you think John I don't know I mean it's right now with all this crap going on and things like that with the government you're I'm looking at six eight months my little self we'll be off the we'll we'll be down there riding the trolley into DC going to the courthouse and I'll be sitting watching I wonder if he'd let they let us live stream. We'll put it on here it'd be neat wouldn't it probably got strong enough they probably ain't got got strong enough Wi-Fi for rivers well I don't know if it's if it if it's um around your areas but you saying that Bethany I've noticed recently around the Alvin C.

SPEAKER_00: 44:06

York hospital there's signs up saying you cannot use any recording devices in this facility.

SPEAKER_04: 44:14

What facility did they say that? The Alvin C York hospital VA hospital Murphy Borough I I was going to say I know the the medical facilities they prevent any type of recording device whether it's audio or video that's all all VAs but I just wonder for something like you know your hearing for the the even with BVA you know I just wonder if they would allow it.

SPEAKER_01: 44:38

I record BVA then you know you know they transcript it is transcribed. But now the use of AIs it'll you get your transcription things like that pretty quick. So you know I mean it's um I think AI is gonna be the future anyway. I think there's gonna be some folks suspect lose their jobs from it because once they get it mastered then your computer will be doing your claim and it won't you know the only problem is say for example your case race they got that stupid denial for age attendance it it wasn't just the writer that did that. Okay. That went to a quality review all right supposing a quality reviewer is a senior specialist that is a quality person that understands almost everything. That's his job he's a jack of all trades. He's supposed to look at that kick back and say hey that can't be right you gotta do this and that but then it went to the signature review.

SPEAKER_00: 45:35

So the boss signed off on it it goes through three different sets of eyeballs it still gets it still gets denied that tells me something else is in the works not not not you know well I was surprised when the regional the southern regional patient advocate called me to inform me that I've won my case and one of his statements was well it looks like you know your way around the VA real well I said I know VA law and I'm gonna try to make you follow it back them into a corner they can't let you know tie their hands AI is a future folks even C and P exams are done by AI now you told me that and I about got the results back first oh yeah yep was it a positive very oh my gosh that blows my mind do you care well I don't I don't know if I want you to share I I'd love for you to share but let's wait and we see what happens oh my gosh okay new topic uh you're right though I think AI is gonna do a lot and a lot of I I worry about my children what they're gonna do with their you know to be successful in their lives because you know AI is gonna take over a lot so I gotta help them figure out yes and computer kids all right well I'm gonna eat years old that's awesome um I'm gonna go ahead and I'm gonna try to get through this we've got about 12 minutes left here and I'm gonna okay go ahead try try to get through my presentation for the first time in how many months.

SPEAKER_04: 47:46

So I want to point out a valuable tool that is it's on our website and you can scan the QR code but I could just kind of want to show you what we're building right now. Let me see what you can see. Okay let me slide this over so you can see my screen. So this is a database it's a live database for users. It's not complete meaning this only contains data from like the last two years maybe not the last 10 but what it does is if a veteran is trying to seek service connection for any condition they can go to this page and they can type in the condition that they're trying to service connect. So because it's a big one let's type in sleep apnea. So anytime sleep apnea has been mentioned in a Nexus opinion it populates with all the ways that we have written sleep apnea. Okay so you can even look at this and see that primarily we write sleep apnea that's secondary. So you can actually filter it and say okay well I just want to look at secondary conditions and sleep apnea. So you can see sleep apnea secondary to PTSD hypothyroidism here we stacked one this one's actually mental health related to sleep apnea diabetes and tinnitus so this is a helpful tool if somebody's looking or trying to consider you know what they are trying to or how they're trying to service connect or if they have a condition that they want to consider filing for these are different ways that we have written the opinion so if we put knee okay we have a back condition secondary to a left knee we have knee secondary to bilateral pes planus. So I just think it's a helpful tool for veterans who are like trying to brainstorm or how they want to service connect something they can plug that in and search. So you can scan it there too if you want to pull that up on your phone. All right couple cases I want to talk about that we've actually done um you we hear a lot how congenital uh conditions cannot be service connected however we have done and been successful with congenital conditions that were aggravated by military service or aggravated by another service connected condition. So in May of this year we had a veteran come to us asking for service connection or for us to write a nexus for their aortic valve disease with an aortic valve replacement as directly related to military service. Okay and so we looked at the evidence that they provided we looked through every single page of his service treatment records and that was so valuable. And we were able to write an opinion saying that the veteran's aortic valve regurgitation was aggravated by a military service and I kind of just want to walk you through that a little bit and I also want you to see where we established a baseline and then we established the aggravation there. So for this veteran we documented the veteran's congenital bicuspid aortic valve anomaly okay that's the medical term it is a congenital heart condition that existed prior to military service. The condition was unknown at the time of entry into the military in March of 1993. The veteran developed symptoms related to the congenital heart condition while on active duty specifically the veteran was seen by a medical clinic on April of 1996 for complaints of heart palpitations with dizziness. It was documented that he had no prior heart problems but that his mother had an aortic valve replaced in 1995 the year prior. He was diagnosed with palpitations with an unknown cause and the treatment plan included consider cardiology consult. So the medical records reflect that just five days later he was talking to his roommate watching a movie when he started to have pain in his right shoulder that radiated down into the right arm. He passed out for two to three minutes as a witness by by witness of his roommate. A cardiology consult was ordered two days later in April of 1996. A Holter monitor was completed and was normal there's a bunch of jargon there but it was normal he was seen as a walk-in to the medical clinic on April 19th of 1996 complaining of fluttering in his heart the EKG was normal at the time of the visit he was diagnosed with palpitations again and his treatment plan included reassurance and to return if he became symptomatic which is not clinically accurate but whatever that's what it documented. So 10 days later he was seen by neurology for a workup of a sinkable episode. The neurologist documented a medical conclusion that seizures were not likely but more suggestive of a panic disorder he was prescribed an antidepressant and it was documented that a neurology follow-up was not required. So the neurologist gave him an antidepressant and said go away. So the veteran wore a halter monitor for 24 hours that's what I was talking about earlier and it was normal and no further cardiology testing was conducted. However it was documented in the treatment records that he was seen by cardiology and the workup was documented as unrevealing that was at his discharge examination. No medical records from a cardiologist are appreciated in the service treatment records. An echocardiogram also known as a heart altrascom was not performed even though it was clinically indicated and medically necessary to diagnose the veteran's symptomatic congenital heart condition. On October 2nd, 1996, it was documented at his discharge examination that the veteran had episodes of palpitations and the workup was negative. At the time of discharge with incomplete cardiology workup the veteran was left with the belief that his cardiac palpitations were the result of a mental health disorder and he was discharged a few months later. After service the veteran continued to have palpitations and he sought treatment by the VA the VA diagnosed him with depression. He was prescribed antidepressants again. This diagnosis reinforced his belief that his cardiac palpitations were the result of a mental health disorder. In 2009 at the age of 39 the veteran began experience decreased tolerance for physical activity a cardiology consult was completed for the first time an echocardiogram showed he had a congenital bicuspid aortic valve with severe aortic valve regurgitation and an enlarged left ventricle so that was 2009 okay and I wrote this nexus or we wrote this nexus in 2025 okay so throughout those you know 15 years he went on to have um a heart valve replaced and he's still continuing to have issues he's on blood thinners um he's all these other complications from this and so in our opinion what we wrote was that the veteran's congenital bicuspid aortic valve was aggravated beyond the natural progression as a result of military service. Based on the timeline of events the medical records indicated that the veteran's heart function was normal despite the presence of the congenital bicuspid aortic valve. The congenital bicuspid aortic valve progressed into severe valve disease as a result of military service. So we've established where it started we've established where it's at now and we go on to talk about the care and I specifically quoted medical literature from 1995 which is when the veteran was experiencing all this and it's important to do that. So then that way the VA knows that you're not talking about 2025 medicine. You're talking about 1995 medicine. So because the proper care was not completed while the veteran was on active duty the veteran did not receive an accurate diagnosis allowing his condition to his congenital condition to progress into significant cardiac disease with complications. During this time his symptoms were incorrectly believed to be caused by a mental health disorder which further delayed appropriate medical treatment so he within a matter of days after we wrote this Nexus letter he was service connected for his um his heart valve and his heart troubles and which we love that because you know when we look at it you know when we we put ourselves in this veteran's shoes you know he really has gone through a lot mentally physically you know this belief that he you know this was all in his head and so when he found out that he really had a physical problem that was significant at 39, you know what did he do all these years? You know you reflect back and this whole time he should have been properly diagnosed and was not so that's the aggravation case I wanted to talk about did he get his uh the breakfast test service connected did he get his what? Did get his mental health service connected we he actually came back to us and got an excess letter for his mental health after that yes so which he rightfully deserved good yes one of many opinions okay well you got a lot of information out there this little show was pretty good today didn't get rushed or anything like that. So I'm gonna pull up my last slide really quick I know we're running out of time but I'll pull this up because I actually meant to do this on Veterans Day and I ran over and I'm about to run over again. So I want I want everybody chesty pooler apart huh?

SPEAKER_00: 58:45

I sure do and that was for Veterans Day and we're a Marine Corps family and uh you know he's a legend in in our understanding and our household so happy veterans day belated on here you need an IMO take a picture of this sucker if you're watching on the video call this number up these folks might help you out of course you have to review your stuff first well guys we're out of time uh Bethany thanks for coming on we appreciate it thank you for having me thank you for coming on and co-hosting buddy I don't know what I do without you glad to do it enjoy it always learn something and and Bethany I'm gonna send that veteran to you to to get an IMO before he goes in for his higher level of aid in attendance.

SPEAKER_04: 1:00:00

Okay.

SPEAKER_01: 1:00:01

Yeah.

SPEAKER_04: 1:00:04

Appreciate it.

SPEAKER_01: 1:00:05

All right. Well, listen, guys, we're going to do it. We'll do this again next week. Uh, we'll have a good topic to discuss, and uh, we don't know what it'll be yet, but uh, I'm pretty sure the weather will be colder, so it'll be something involving Cocoa and hot coffee. Yeah, and with that, this will be John Jay Basher on behalf of Bethany Speinberg and Mr. Ray Cobb, and Jay Basher's Exposed Vet Productive, then our producer will be shutting her down for now.