SPEAKER_01: 0:02

Welcome, ladies and gentlemen, to another edition of J. Baster Exposed Vet Productions on this so what beautiful day. It was a balmy day here in Kentucky. Wind blew a little bit. November the 5th, 2025. Pretty soon it'll be 2026, because 2025 will be a blur. I got my co-host sitting on top of the panel up here, Mr. Ray Cobb.

SPEAKER_04: 0:26

How are you doing, Ray? You may have a little technical difficulties.

SPEAKER_01: 0:35

But we'll go ahead and get her started. Our guest tonight is the owner of a company called Valentin Vet. They do independent medical examinations and opinions for veterans who need assistance with the VA claim. And uh they look at your information and they determine, you know, what's best for you. They've been doing this for quite a while. Her name is Bethany Spiningenberg. Um Beth, tell us a little bit about yourself as far as uh how Metal Fit goes and what your relationship is with those guys.

SPEAKER_02: 1:08

So um how do I start? So I am a physician assistant. I have been a PA since 2000, practicing since 2010. So I've been at this for a while now. Um my very first job was at the VA in primary care, which was a huge learning curve for me. Uh, lots of chronic illnesses, um, multi-diagnosis, just a lot of complex cases. And so the learning curve was rather steep on that, but I enjoyed every bit of it. When um my husband was deployed, he was in the Marine Corps, he was deployed overseas. And when I uh when he was deployed, I was working like 60 hours a week in primary care. I got paid my 40-hour paycheck. But when he was deployed, you know, there's nobody at home. I just worked my tail off. And so uh when he got back, I wanted more simplistic schedule, something that I wasn't exhausting myself over because my entire relationship or our entire relationship, he was in the military and I was in school or um getting a job back home in Ohio. Um and then that's when they had an opening in the specialty clinic and I transferred to compensation of pension. I had no idea what it was about and um learned a lot. I was the only full-time provider there. We had other providers that would come in and kind of fill in when the load, uh workload got high. Uh, anything that came off the printer from Cleveland Regional Office, I had to review and sort and decide what provider that went to, what department that went to. Um, so I got a lot of firsthand experience in the comp and pen world. And then when my husband got out of the military, he applied for his disability benefits. And two years later, he was denied for his benefits. And so at that point, I got really frustrated. Uh, Secretary Shinseki was in and he decided that he was going to make sure that the timeliness was taken care of, and he wanted the um department to close out all of the claims that were two years or older. And what ended up happening is when crunch time came, instead of actually processing the disability claims, they um denying veterans and forced them into an appeals process. So at that time, that was 2013 or so. Um I just got tired of the VA way because I was going 110 miles an hour trying to work my tail off as a new PA, trying to climb the ladder and getting nowhere fast. So I ended up leaving. I um went to the civilian side of things and started practicing in occupational health. And I've been in occupational health ever since. When I left the VA, the local county service officer actually was the one that was like, Hey, I need your help still. We have veterans locally that are from your community that are really struggling for their service connections. You know how this works. Can you help us out? And so I started doing Nexus Letters for our county service officer and our local veterans. And then I decided, you know, I needed to keep this going. And I um became accredited so I could learn law and understand, you know, what attorneys we're looking for. And I learned alongside them. I work directly with them, and we've continued to expand our knowledge and experience in writing Netflix letters and doing some DVQs for the veterans. So I know that's a little long. It's uh this is something I feel like has been the path that I was meant to be on. And so it does very much define who I am and the life that I live. And outside of this, I have three children.

SPEAKER_04: 5:06

So you gotta live too, you know.

SPEAKER_01: 5:19

Right? You stay with us? Can you hear me?

SPEAKER_02: 5:25

It looks like he's trying.

SPEAKER_04: 5:28

I think he is.

SPEAKER_01: 5:29

I don't know what's going on there.

SPEAKER_02: 5:40

So the presentation today, it's really going to discuss some of the foundational things when it comes to independent medical opinions and just medical opinions in general. Understanding um, you know, where in the disability claims process they fall, um, when to get a private medical opinion. Um we'll talk about some cases that we've actually done at Ballot for Vet. And um I think it's actually very well when we first talked about doing this topic, I feel like, you know, personally, I beat it with a dead horse, but it is something that I'm, you know, I've I've got my my focus on one thing. And so it feels like it's something I do every day, but not necessarily something that other veterans get to hear or understand every day. So uh when I reflect on this, I'm like, yeah, there's actually some content in here that would be helpful for our veterans now and other veterans trying to get a service connection and understanding, you know, where the medical opinion um plays a role in VA disability claims. Any questions before I get started?

SPEAKER_01: 6:49

Um, I mean, you know, a lot of folks uh I've seen this a whole lot in the past couple of months, especially since the first the shutdown started. And it's just usually one question or the other. Everybody's asking, you know, well, I got denied by the VA. Where do I go get a you know on a medical opinion? And uh see your names come up, so you know, your company has come up several times. And uh you're talking groups of 80 to 100,000 people. And uh probably one of the reasons you guys are so busy.

unknown: 7:22

Yeah.

SPEAKER_02: 7:22

But we are we're we're gonna have to put a few more hands on this kind of work. Uh I've actually already thought about it because the providers that we've had we have right now, we've had them for four or five years. I mean, all of them. And so um they enjoy this work, they've learned right alongside with me. Um, I'm I've honestly I've I've handheld them even now. Like that sounds terrible to say, but I'm very particular when it comes to understanding these cases and really trying to advocate for the veteran. So, yeah, it does kind of slow things down, but it also does several other things that also make sure that the product that we put out is a quality product, that it follows the current VA laws and you know what is needed for that veteran's case. Um, and for me to even bring somebody new on, the amount of training would take a solid year for even, you know, they could probably help speed up the process within three or four months, you know. But the actual training and for them to understand what we're doing would take well over a year. So I don't know. We'll see how that goes.

SPEAKER_01: 8:32

But um the one thing I do like to also go ahead and I think you mean you gotta train the way, you know, because I mean they're doing nexus letters, you're gonna have to realize I'm gonna have to learn the process. You know, and uh they're gonna be educated, you know, they can do the medical side of it, true, but you gotta realize that the VA situation and the way that they look at the education parts of the claims versus the Title 38 and just making the nexus to service itself can be it can be a monumental task.

SPEAKER_02: 9:04

Yeah. So I mean there's so many moving parts of this as well. Um, you know, we even watch some of the the denials that we see, we're trying to watch and see what kind of patterns that the VA is putting out, what kind of templated language that they're putting out. And so we can kind of get ahead of that. So if we see that somebody is going to get denied for, let's say they're migraines and there's a templated uh denial language in there. So we try to jump ahead of that and address that um, you know, that templated language ahead of time so they can't spit that out. So I mean, it's not just about writing Nexus letters for us, it's really understanding what is moving and and happening at the VA, at the regional office, at the board level. Um, you know, that that's that's why this is what I do day in and day out. The other part that I wanted to talk about that sets us apart is um the team approach that we have. Again, that adds more time, that adds more work. But if you really break it down, what that does for us as a company is it means that all of our we we have a checks and balances in place. So some of the other Nexus letter providers, they they spit stuff out left and right, and it's really kind of questionable, you know, whether they're truly applying the medical, uh, the medical literature and the veteran's history, or are they just, you know, copying and pasting from one Nexus letter to another? Well, for us, you know, there's there's two hands at minimum on everything. So when a veteran dumps their file in our lap, you know, one provider will go in and say, okay, we think we have a nexus here. Then a second provider goes in and goes, oh no, there's no nexus here. Or they'll say, Yeah, this isn't this is a nexus, and I agree with that, that rationale or that uh connection and that theory that you're going with. And so if the VA ever comes back to us, you know, we're not putting our finger on one person that's processing templated nexus letters. You're looking at a whole team, and you got this, you have to stare at the whole team and say, you know, we're doing this collaborating collaboratively. We all have our medical license, we've all had the VA training, we've been doing this for X amount of years, and we make each other accountable. Same thing for um when we put out our DBQs. We look and see, you know, is our psychologist blanket putting that everybody's occupational and social impairment is at total. Is he doing that for everybody just so everybody can get an increase and get their max? No, there's checks and balances in there. We look at every single case and make sure that they're actually doing their work, discussing the veteran's case and applying, you know, or clicking the boxes that truly pertain to that veteran. So there's a lot of checks and balances in what we do that keep us accountable as a company, keep our reputation out there and a positive light. And so that also comes back and benefits the veteran in the long run.

SPEAKER_04: 12:09

So you have to.

SPEAKER_02: 12:18

All right, let's get started.

SPEAKER_01: 12:21

All right, it's party time.

SPEAKER_02: 12:24

All right. So this is what we're gonna talk about today. Uh, we're gonna learn what a medical opinion is and how it uh its role in VA claims, its purse, its purpose, its placement, when you need to give an independent medical opinion, how to work with uh independent medical experts such as Valor for Vet, um, what evidence what evidence the veterans need to get to collect so they can give to us and to whoever they're taking an independent medical opinion from, and why they're submitting that evidence. And then we'll talk about some case examples. What is the medical opinion for VA claims? So a medical opinion, and we're talking about whether it's the VA or whether it's a private medical opinion, a medical medical opinion for VA claims 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, illness, injury, or another service-connected condition. So these medical opinions, when we say a qualified health care provider, that is broken down by the VA. And what they want to see in a qualified healthcare provider is an MD, a DO, a nurse practitioner, a PA, an audiologist that has their uh doctorate and a doctor of audiology, a psychologist with a PhD. And then there are some other caveats, um, but they also have to take the VA required training. And that what that's what defines them as being a qualified health care provider. So sometimes um when veterans go to their primary care provider and they're asking for an excess letter, yeah, they're licensed, but the VA may look at that opinion that they provide and say, well, they're not qualified because they don't have the VA training, and because the VA examiner has the appropriate training, they're considered to have um, you know, a their opinion holds more weight against another provider. So that's again one thing at Valorant Revent. All of our healthcare um experts or medical experts that write these in explicit letters, they are qualified. We've done the VA training, we hold our medical license, we get continuing legal education, continuing medical education. And so when it comes to comparison or using our opinions versus the VA opinions, the weight of our opinions are up there just as uh solid as another VA provider. An independent medical opinion or an IMO. So an independent medical opinion is a medical opinion for VA disability claims that is written by a non-VA qualified healthcare provider that addresses whether the veteran's current medical condition is related to an in-service event, illness, injury, or another service connection. So the only thing I'm trying to really emphasize here is that when we talk about IMOs, and there's different synonyms that we use or different language that we use, but when we talk about this, we're not talking about going and getting an opinion during the comp and pen. We're talking about seeking outside non-VA, non-contract opinions. So the synonyms that we use, we talk about IMEs, so independent medical exams that's used interchangeably, IMEs, IMOs, uh a nexus letter. That is the verbiage that we use at Valid for Bet Nexus letter, you're gonna hear me use all of these terms in, like interchange all of them, but primarily the service that we provide or the product that we market is a nexus letter. So you're gonna hear me primarily call it a nexus letter. A nexus opinion, a medical opinion or a private opinion. So all those terms that your VSO, other veterans uh may discuss, your attorney may discuss, those are all talking about getting an IMO or a nexus letter for your VA disability claim. So let's talk about the purpose and the placement. So the purpose of a medical opinion is to confirm or roll out whether a medical condition is related to military service or secondary to another service connecting condition when it is not automatically presumed by the VA. So when a veteran has a disability such as sinusitis, and they have verified deployment or service in Southwest Asia, the sinus condition is presumptive. A medical opinion is not needed in those cases. So in those cases, the veteran should automatically be service connected. We've seen where that doesn't always happen, and we have to step in and provide an opinion. Sometimes veterans can elect to get legal counsel and fight that because it should be presumptive. Um but the primary role for medical opinions is when the condition is not considered a presumptive and you're trying to tie it to service or to another service-connected condition.

SPEAKER_04: 17:38

Any questions so far?

SPEAKER_01: 17:43

I think in the case of that, then if they do send the veteran out for an examination presentative condition, they sh I believe their only responsibility would be to get a current level severity of the condition.

SPEAKER_02: 17:57

Correct. I'm glad you brought that up because the medical opinion doesn't give you a disability percentage. The examination is what gets you a disability percentage. So while the sinusitis may be presumptive, you're still gonna have to report for an examination so the examiner can look in your nose and see what the inside looks like. What it looks like on the inside of your nose will determine how much compensation you're gonna get at the end of the day. So the placement of a VA opinion. What I mean by placement is where it falls in this process. So if we look, this uh uh picture is actually created by the VA. This is the VA claims process. This is on one of their PDFs they used to give out. And the VA claim exam and um the opinion falls under step three. It's considered the VA's way of gathering evidence. So when do you get an independent medical opinion? Okay, so in this one, in step three, this is where the VA providers will provide an opinion if it's not a presumptive condition. So when do you get a non-VA medical opinion or an IML? So I let me jump back again. Sorry. I put the chess board on here because it is a very strategic concept when you really look at how you're maneuvering some claims as a veteran who is a party of one and they're trying to navigate or or play chess, you know, for their claim, it's a very different perspective than somebody who looks at medical opinions and rating decisions all day long. So what I'm telling you uh in the Next few slides is what I have witnessed and what I've seen and my experience and when to get an IMO. So visiting step three. Okay. Let's go back to the beginning. When you file an intent to file, you should make sure that you have your doctor visit where you have a current diagnosis. Okay. So you're gathering your medical evidence that shows the current diagnosis. You're putting together a statement that talks about your claim, talks about how you're relating it to something that happened in service or to another service connected condition. Then you're going to gather the historical medical records, whether it's from the claimed condition you have or for those other service connected conditions, you want them to understand where your whole medical picture sits. Then you put in that application. The reason I want to back up before that claim is received by the VA, because all of this evidence that you're putting to the VA will eventually get into in front of the CMP examiner. And you want them to have it from the very beginning. So if you decide there's an option for you and you're a 526 Easy to file a fully developed claim. And what a fully developed claim means that the VA has to do no work in order for them to gather your medical records, get any other uh statements from you. What you're saying is that the package for my claim is complete with a bow and it looks pretty. And you're delivering it to the VA and you're saying it's a fully developed claim. A lot of those who file a fully developed claim, including VSOs, they will want to get a medical opinion when they put in that application. That way, whoever is rating it or providing a decision to service connect or not, they've already got everything they need to decide that claim. If for some reason the VA feels that you don't have your package put together good enough or well enough, and a pretty bow on top isn't as pretty as you think it is, they will take it out of the fully developed claim process and put you into the standard claims process. So this is just something I've seen firsthand for some VSOs. There's certain um VSOs that like to go get ahead of the game and get that IMO in there. So then that way the VA can't uh they're actually working against um, how do I say this? The the veteran is going in with an edge. So they already have all the positive opinions and information that they need in order to get service connected. So at that point, anything beyond that, it's it's the VA fighting the veteran to get service connection. So um some VSOs, some veterans feel that going in with an excess letter uh makes our case stronger. And my personal opinion, if I'm a veteran and I'm tied on money, depending on what the case is, I may not get a nexus opinion beforehand, mainly because there are some medical conditions that are clearly tied to service or clearly tied to other uh service connected conditions. And so, in my opinion, it's it's a win. So, for example, if I have a veteran who is claiming sleep apnea secondary to PTSD, if they do not have sinusitis, if they do not have obesity, they're thin, they have no sinus issues, but they have sleep apnea, and their only risk factor is PTSD, I want them to file that claim without buying an opinion. Mainly because it's now a matter of deducing what is the cause of this individual's sleep apnea. And when you have very limited risk factors, it's it should be a walk in the park. Okay. So if we go back and we look at this claims process and you do, let's say the traditional claims process, and after step eight is complete, you get your rating decision and you get a denial. At that point, you can get an independent medical opinion. And what we're really trying to do here is we're trying to look at what that medical or that VA examiner said, what opinion they provided, and we're going to try to look and see if we can refute their opinion and if the medical evidence is there to write a nexus in support of your claim. After you get your IMO, you can put it into a supplemental claim and it could be processed as new evidence, new and relevant evidence. You do not want to get an IMO and do a higher level review because the higher level review will not look at that IMO. They will only look at the evidence that was available at the time of the initial decision. So we're going back to step eight, and the higher level review is only going to look at what evidence was present when step eight occurred. So if you get an IMO after that rating decision comes out, they're not going to look at it. So you need to file a supplemental claim when you take a nexus, a private nexus to the VA.

SPEAKER_01: 26:08

Yeah. Anything new, if it's new evidence involved, it has to be a supplemental. Basically, a I call it a DRO, which basically is the um the same thing, in my opinion. It's based off evidence of record. And they can't add nothing new on the high-level review. It's just a DRO reviewer looking at it.

SPEAKER_02: 26:30

So I like to tell a lot of the silly stories that the VA does because it makes me feel sane sometimes. Um, because definitely when I see some of the things that come out from the VA, I feel like I'm crazy. Um, but recently we wrote a medical opinion, and I'm working with the VSO on this. We wrote a medical opinion, and they they came back in their rating decision and they denied the veteran. And they said that they could not use our Nexus letter because they could not verify the medical experts' um license and NPI. And they said that we did not provide a license or an NPI on the Nexus letter. And I laughed because our Nexus letter always contains the medical license and the NPI and the name of the medical expert. However, the VA said it was not new and relevant because we can't take that opinion. You don't have an NPI and we can't verify the license of the medical expert. So I pull it up, I pull up the medical opinion and I show it to the VSO and he pulls out what he faxed over. And we're like, yeah, it's right here. It's right in the letter. Like we've they didn't even read the letter letter, they didn't even care. They just denied it. And that's why I'm like, I'm crazy. And so the VSO, we kind of we're talking about it. And he's like, So do we get a new medical opinion? I was like, no, like, why do you need a new medical opinion? Because all of it's there and what they're saying is not true. I said, submit it for a higher level review. And if they deny that, then we'll do another medical opinion. But right now, with that nonsense, that's you don't need to get another IMO for that. So if after the supplemental claim, uh, once you submit the supplemental claim with the independent medical opinion, the whole process starts back over. So you're going back to step one and going through that whole process. And the VA may get a second opinion to say, no, it's not, even though you have one that says it is, and they're supposed to go uh in favor of the veteran. So we often find ourselves going through this continuous hamster wheel. So this is an AI-generated image. I know we've talked been talking a lot about AI. There's actually a few AI things in this presentation, which are rather comical. So we'll talk about that as we go through here. But this is that that veteran hamster wheel. Um, and what the VA, this is what my vision was of the VA. This is actually from a few years ago. So it's just it can be exhausting.

SPEAKER_04: 29:27

Any questions?

SPEAKER_01: 29:30

I like to hear it too well. I don't think the Marine Alert lacks it too well, though.

SPEAKER_02: 29:39

All right. So, what evidence veterans need to gather before getting an independent medical opinion? Let's go back and what they should be gathering before filing even a disability claim. Okay, because what what we need for an IMO is what the VA examiner needs. Okay, so let's talk about this. So the VA claims process, again, we're going back to the beginning. We're going back to before we even think about filing that claim. You are gathering your evidence. And I took this training here. This is actually a VSO agent training, and this is one of the slides on their training. And I want to emphasize what they say to obtain for your claim. Okay. I'm going to read it together or for with you. Service records, including personnel records, service treatment records, via health records, such as outpatient treatment reports, diagnostic test findings, hospital summaries. If they put you out into community care to have a sleep study, to have a nerve conduction test, you need to get a copy from them and submit it directly to the benefits, to the evidence intake center. Do not depend on the VA to provide it to the evidence intake center because what happens is when they get those private community records, they get scanned into the system. That scanning system is not inside the access of the benefit center. So you have to physically get those copies and submit it to the evidence intake center. You need your military treatment facility records. If you were hospitalized during service, try to get those. Any VA examination reports, such as a negative comp and pen exam, a negative comp and pen opinion, you need to get those. Marriage, divorce, birth and death, death records. Now, for us doing independent medical opinions, we don't need marriage, divorce, or birth records, but we do like to see death records if there is a widow or a dependent trying to claim death benefits. We do need that death record. Okay. So this is information coming from the VA. This is this is they're telling you, hey, we need all of this before you go and file a claim. This is another one. Okay. They talk about in this training session, they talk about non-original claims. So an original claim is the very first claim a veteran ever claims. And with original claims, there's a lot more work on the back end of the VBA that they have to do in order to process it. So this is a non-original but new claim. Okay. So on this, we're emphasizing in cases where a new service connected condition is claimed, the VA will need evidence that the claimed condition exists. That it exists. You can't go in claiming something that you've never been seen or treated for. You can, but your chances are not good. So for example, if the veteran is claiming service connection for a prostate cancer, we will need evidence that they have the condition. Medical evidence of a diagnosis of the condition would be the best evidence to submit. Go to this slide. Same thing. Usually medical evidence with the diagnosis of the claimed condition would be the best evidence to submit. For example, if the veteran claims they were treated for a duodenal ulcer, so that's a stomach ulcer in service and they were separated more than one year ago, we would need a medical provider statement that they are currently treating the veteran for an ulcer to establish a current disability. So these are kind of unwritten rules. Okay. So this is the VA saying, hey, if it's been more than a year, we want a current diagnosis. So this is why I, when I talk, and I have said this for a long time, that if you're claiming something, you want to be sure you want to be seen for that condition with within a year. If your appeal takes five years and you haven't been seen for your migraines in five years, good luck. If your appeal takes five years, but you've seen a doctor every year in those five years for your migraine headaches, that improves your chances significantly. So this is unwritten rules as far as it comes to what the VA does, but in the training for the VSOs, they're certainly pushing this idea to the representatives. Any questions before I move on to the next section?

SPEAKER_01: 34:42

Not to mention that a lot of conditions are actually presumptive for the first year after service.

SPEAKER_02: 34:47

Correct. Arthritis, if you have x-rays that show arthritis in any joint, that's presumptive. It's like arthritis of the shoulder within 12 months. That's an automatic presumptive service connection. Any other questions?

SPEAKER_00: 35:06

Bethany, I have a question. Um if if last night John and I both had a phone call from the same veteran, uh Clarkson, Tennessee. And in talking with him and what you just got through saying, I don't think from what he read to me, did I hear at any point that the doctor made the statement when he did the diagnosis for foot drop, gave the diabetic shoes, gave the brace. Two different doctors saw him uh and agreed to it, and yet neither one of them said secondary to diabetes. Isn't important that those doctors put that in their notes as well.

SPEAKER_02: 35:57

It is if you're trying to go without a um, if you're trying to get an easier claim process. In my clinical experience, it is standard for me to say neuropathy due to X, Y, and Z, because I'm I'm documenting my clinical findings and observations. If there's a neuropathy condition and I don't know what it's what it's for, then I'll put unknown workup in progress or referral to neurology or something like that. So, and it and it varies because the quality of care is not the same everywhere. So, what may be somebody's standard practice in and when they see their patients is not necessarily standard for another provider. But yes, that it would help the veterans significantly if they would say, um, you know, diagnose it, like in what we call soap notes. Uh towards the bottom, they have what this what's called the assessment and the plan. And sometimes they're combined together. And so they'll number them out usually, and they'll say diabetic neuropathy, and then they'll put has foot drop um referred for to podiatry for custom orthotics or an AFO or something like that.

SPEAKER_04: 37:13

So um it would be very helpful that the language is in the medical treatment records. Okay.

SPEAKER_00: 37:25

Um from what he read to me over the phone last night, he did not have that information uh as part of his evidence, and the board sent it back to the region asking for more evidence. Um I'm anticipating that might have been what they were looking for.

SPEAKER_02: 37:45

That's where I would absolutely start, and I would try to get those private treatment records either modified, get a new visit, um, do whatever I can to get that private provider who's treating that veteran to make sure that connection is placed in the medical record. Um, we actually, because you're talking about neuropathy, go ahead.

SPEAKER_00: 38:06

Yeah, I was just gonna ask John if he'd said anything to you last night about that the doctors had pointed out that it was secondary to his diabetes and neuropathy.

SPEAKER_01: 38:20

I think he just took that for granted, but no, they didn't say anything like that in the in in in his opinions. Of course, no, he swears looking down at the VA. He filed his claim back in like 2016 or whatever the VA has it. Looked at it. Nobody's looked at it, even the BBA didn't look at it. At that doctor's opinion. As far as his B concerns. He's already struck the diabetes anyway. You know, so I mean it's kind of like you know, I would understand, I'm sure Beth would understand a lot of understanding that we're like diabetes, but you know, you can the VA is not gonna assume nothing because the VA is doing the cost of money. So you know, we've got to get on the 21st of what it's five picking everything. He needs to get that doctor to say that the neuropathy is due to the diabetes. Whatever it doesn't matter if it's foot drop or you have to do is make sure the neuropathy is secondary to the diabetes. I mean, it may already be that way if you already checked for neuropathy. So it could be a moot point.

SPEAKER_02: 39:34

You know, there's a couple other avenues that they could possibly go for when you're trying to do that, is if he's ever had a nerve conduction study, and the only type of neuropathy that's found is the small nerve fiber neuropathy, and there's no large nerve fiber, there's nothing coming from the back or compression behind the knee. If it just shows that he has objective evidence of just a small nerve fiber, that would show that he has a diabetic neuropathy. So he could submit that if he's ever had a nerve conduction study test done. The other thing that he can do, and sometimes I recommend this to veterans, because some of the VA providers get really frustrated that a lot of their work is to get disability benefits for the veteran. Now I know that sounds silly, but it does add extra work on top of the already overwhelmed provider. So what I typically say for somebody like this who knows that their neuropathy is from their diabetes, that's trying to get that service connection is you when you go in the next time to your provider, you can make an early appointment, just a follow-up or whatever, and just say, you know, nobody's really ever talked to me about why I'm having this foot drop. Can you help uh explain this to me? And you know, the doctor can go through and they can talk about it. And if he comes out and says, Well, it's because you're diabetic, you've had diabetes for so long. Well, can you document that so that I can take that with me so I I can tell my family or I can show whoever, you know, that it's related to my diabetes, or you know, I had another provider, you know, didn't understand why, where my foot drop came from. This would this would be a better picture. Just kind of play dumb in some in a sense, because you're really, you're really trying to get that provider to expand their medical thinking and basically going back to the very the very basics of patient care and trying to trigger that process for them.

SPEAKER_04: 41:35

Does that help? Yeah, it does.

SPEAKER_00: 41:39

I mean, yeah.

SPEAKER_02: 41:42

So when you talk about the neuropathy, um, I do want to mention really quickly, we had a case kind of similar to that, but it was like the opposite. So he came to us and he wanted us to write a Nexus letter saying that his nerve damage was the result of his service connected back condition. And as silly as it may seem, um, right in the record from the nerve conduction study, it said that the veteran had no evidence of lumbar ridiculopathy. I mean, black and white, no evidence whatsoever. And that's that EMG, that nerve conduction test looks at the numbers that come off the nerve signals. So in that, I can't argue that I can't say it is whenever the nerve conduction study says it says no lumbar ridiculopathy. What it said in there is that that individual had a small nerve fiber neuropathy. And it was what what they call demylating. So like the fat around the nerve was actually no good, like it wasn't conducting well. And so in that case, like we go back to the veteran and we say, hey, it's not related to your back. You have some other metabolic process, whether it is diabetes, whether it's rheumatoid arthritis, whether it's multiple sclerosis, something. But you need to go talk to your primary care provider about what's causing it because there was no evidence in the record of what was causing it. So, in a similar fashion, we were able to use the nerve conduction study to say, oh, it's clearly not from your back, but it's something else, and you need to go get it figured out. All right. I'm going to try to push through the last few slides here because I want to get to talking about some of our cases. So, um, so what evidence do veterans need to gather before obtaining a private medical opinion? Everything that the VA said in their training, everything that you should be providing to your VA examiner, you should be providing to your non-VA examiner or medical expert. Okay. So why is that information needed? So this slide is another training slide from the VA. And the reason why I'm putting this out there is because I want everyone to see what they're asking of the medical examiner. Okay, so let's zoom in a little bit. So if we look on the left-hand side, I know this specifically talks about TERAS or toxic exposure-related activities, but these apply or this thought process applies to every Nexus letter that we put out. Okay, so if somebody's trying to claim seizures, we're trying to look at, you know, is it hereditary? Is their brain tumor hereditary? Is there brain tumor that's causing seizures hereditary? So we're trying to really think, break this down of where this condition is coming from. Um, is it congenital, which means did it occur at birth? Is it from their smoking history? Is it because they're overweight or underweight? Is it because um, you know, something in their labs is abnormal? Is it a multitude of things? And so we're really trying to look at every medical condition and how it plays in the veteran's military history as well as um genetics, birth, prior smoking history. We're looking at all those complex components. And if you look at the right side, they want the examiner looking at terrorists, whatever's being claimed, they want to understand the onset and the course of the claimed condition. That applies for every medical condition. If you're claiming diabetes, we want to know when you were diagnosed with diabetes. What symptoms were you having? Did it get worse? Are your labs, what have your labs shown? Is there a history of showing uncontrolled diabetes? For example, we had a veteran claiming a stroke secondary to diabetes. Don't know if you knew it, but if your sugar's too high, it can actually cause a stroke. Okay. So in this case, we were able to show that at the time the individual experienced their stroke, their sugar was 800. So we were able to understand his chronic history of the disease, how the disease had progressed, what treatments have they had. And that that applies to every condition that you are trying to service connect. Us in the medical side of things, we really need to understand that timeline and how things come about. And you'll see that or appreciate that when we talk about some of these cases. Any questions before we jump into the cases? Um there is one more case I would like to talk about with this really quickly. So recently we had a veteran try to service connect their, they had a tumor on their pituitary gland. Pituitary gland is in your brain. And sometimes those get tumors and they can mess up your hormones and cause all kinds of things. Well, what's crazy about it is his mom also had a pituitary tumor. Okay. And so the VA examiner said, well, it's not really the disservice because it's hereditary.

unknown: 47:01

Okay.

SPEAKER_02: 47:02

So we look at the case and we're like, this guy's 64 years old when the first time he gets diagnosed with the pituitary tumor. Like if it's hereditary, it's normally in your younger years. It's normally when you're in your 30s that you get signs and symptoms of this pituitary tumor. And it's only hereditary in 15% of the cases. Well, he has a positive terror. They came out and said he was exposed to all these different chemicals. So when we look at the case, we're like, okay, he's 64, he's a non-smoker, he had no symptoms until he passed out and had to go to the ER. I would have to argue it's not hereditary because he wasn't, you know, at the age of onset, the time his mom got it, there's no correlation there in the fact that it's 15% hereditary. So we're writing a nexus saying it's an it's at least as likely as not. We're sitting the fence 50-50. It's just as likely it's related to service and his exposures.

SPEAKER_04: 48:00

Um, so that was a very interesting case that we recently got.

SPEAKER_02: 48:10

So case examples. So we've talked about AI quite a bit. And this picture here is from a couple years ago when AI first came out, and I asked AI to create a picture of a physician in a white coat examining the knee. And you can see that there's no anatomical accuracy in this leg with no body. So I found it rather comical. Pardon?

SPEAKER_01: 48:47

You gotta cut your knee off and examine it and put it back on now.

SPEAKER_02: 48:51

Right. Um it actually looks like some of my slides did not carry over.

SPEAKER_04: 49:02

Okay, so let me I'm gonna actually um see if I can re-download this really quickly. That's strange.

SPEAKER_02: 49:28

So you may have to unshare me real quick if you don't care. Do you care to um oh wait, I guess I can leave, can't I? 'Cause I gotta step out and pull this up really quickly. There we go. This that's a picture my daughter made, by the way.

SPEAKER_04: 50:20

Okay.

SPEAKER_02: 50:24

Okay, so I'm going to because this is all the cases. So I gotta show you the cases. Let's see. If it doesn't pull up, then I can um just do it by my yeah, it's not gonna let me. All right, well, let me just go through these cases, okay? So our first case is Jeremy. And Jeremy service connected for his back, ridiculopathy, and both his left and right legs, right ankle sprain, and bilateral flat feet. And he wanted us to look and see if his neck condition, bilateral knee condition, and bilateral shoulder condition were related to service. He served in the Army from August of 1998 to September 2002. So we have about five or six years of service there. And when we did a basic record review, we looked at the evidence that he provided to us and we determined that we could not write a nexus for his cervical spine condition. And the reasoning that we gave is that based on the available records, there is no documentation addressing the progression of the cervical spine condition after military service. We noted that there are no treatment records for your neck following service until the age of 43. Information about your occupational history after military service was not included, which limits the ability to fully assess the potential contributing factors. So we could have looked at his x-rays at or a CT scan of him at 43, and we could have compared, like, you know, related to your service, your time at service based off of your specialty in service versus post-occupation and that progression, there's too many missing pieces there. So we did not feel comfortable saying, yeah, it's at least as likely as not. So for his neck, we couldn't write a nexus course. For his bilateral shoulder condition, very much the same thing. There are no treatment records for your bilateral shoulder condition, period. There was nothing that was provided to us regarding his shoulders and medical treatment for his shoulders. But there was a common pen examination completed in November 2024 that noted bilateral shoulder strains. Information about your occupational history after military service was not included, which limits our ability to fully assess the potential contributing factors. So if we look at a bilateral shoulder strain 20 plus years after service, we don't know if that strain is coming from what happened 20 plus years ago or what's happened since that time or during his occupation. There wasn't a statement that was provided. There was very limited information to understand that medical condition. However, we were able to write a nexus for his knee condition. So we determined that we could write a nexus saying that his bilateral knee arthritis is secondary to the cervicinetic condition of lumbosacral strain, bilateral lower extremity radiculopathy, and his right ankle sprain due to obesity as an intermediate factor. So, due to time, I kind of just want to break it down a little bit. Um, so we talked about that after his discharge in 2002, the veteran reported ongoing musculoskeletal pain related to his service that limited his physical activity. In his statement or in a statement, both the veteran and his mother explained that he began gaining weight after leaving the service because pain from his service connected injuries. It made it hard to exercise and stay active. A recorded weight from February 2016 was 263 pounds, corresponding to a body mass index of 38, which is obese. We discussed the lung bar X-rays from 2016, the knee X-rays from 2016. We discussed that in November 2023, his body mass index increased to 42, which is even more weight and higher obesity and increases the risk of arthritis in his knees. So we talked about a 2024 VA disability exam that documented pain with forward flexion of the lumbar spine, which is his cerface connected condition. We talked about the moderate verticulopathy involving both lower extremities. And another disability exam that in later that year documented a right ankle with moderate limitation of motion, painful motion, and evidence of fatigue. So all these service connected conditions are supporting his reports that it made it difficult to exercise. So a VA examination dated July 2025 confirmed a diagnosis of bilateral knee strain at the generative arthritis. So I want you to hear this opinion and how this opinion lays out when we talk about obesity as an intermediate step. Okay. So we said the veteran's bilateral knee arthritis is more likely than not secondary to the condition of lumbosacral strain, bilateral, lower extremity radiculopathy, and right ankle sprain. The veteran's lumbosacral strain, lower extremity ridiculopathy, and right ankle sprain caused the veteran to become obese. Obesity is a substantial factor in the development of the veteran's bilateral knee arthritis. The veteran would not have developed bilateral knee arthritis if the veteran was not obese. And this individual, we're looking at a body mass index of 42. That is a that is a very large individual. And so, you know, we go on to talk about you know the medical evidence that supports that timeline that we provided. And that nexus letter is six pages. I'm not going to read all that to you.

SPEAKER_01: 56:37

We don't lose a bunch of weight.

SPEAKER_02: 56:39

I'm looking at diabetes, I'm looking at hypertension, all that stuff. Um, the next one I want to talk to you about, and I know we're pushing close to time. Do you care if we go over a few? Is that okay?

SPEAKER_01: 56:54

Okay, a couple of this.

SPEAKER_02: 56:56

Okay. All right. So maybe I'll just talk about this one and then we can we can be done and do questions. But all right, the second one we're going to talk about is Dan. So Dan served in the Army from 1970 to 1972. He was deployed to Germany in September of 1971. After he got out of the Army, he served in the Army Reserves from 1972 until 1994. He came to us, he had no service connected conditions. And he came to us and he says, Hey, I want to try to get an excess for my thyroid and throat cancer, the chronic fatigue syndrome that I have, and my sleep apnea. And we said we could write an excess for all three. And here's why. In August and September of 1971, while stationed in Frankfurt, Germany, the veteran was hospitalized for approximately 10 days to a severe episode of infectious mononucleosis. During this hospitalization, he experienced a high fever, recorded up to 103 degrees Fahrenheit. Laborator evaluation at that time demonstrated a positive mono screen with an elevated white count, confirming the diagnosis of mono. We go on to talk about post-service medical history. And he began to develop symptoms of chronic fatigue in the 1980s. He reported experiencing sporadic and debilitating episodes of fatigue that would last from one to three weeks at a time. Epstein-barr virus is the virus that causes mononucleosis. So he had this infection of 71, and he still has antibodies in his system that are running around and not being controlled by his immune system. And in June of 2016, that many years later, it's still elevated. Later that year, he ended up getting uh cancer and had radiation treatments, which further attacks his immune system, makes it to where it doesn't work. And that fatigue really kicked in. So his doctor in June of 2018 said it uh documented his fatigue and that it might be linked to his history of uh mono from service. We talked about his doctor from October 2019 that discussed his fatigue. Medical records from July of 2020 included another blood test, which confirmed persistently elevated Epstein-bar virus levels that were far above the normal reference range of less than 18. His was 446. So we're showing this ongoing history of this positive Epstein-Barr virus that he was documented to have in 1971. Well, that virus stayed in his body and went on to wreak havoc, causing the chronic fatigue, causing his throat cancer, causing his thyroid issues. His thyroid cancer. So we were able to write a nexus for those. And then we took the sleep apnea and said that his sleep apnea is most likely tied to his chronic fatigue, his thyroid cancer, and his throat cancer. So we were able to write a nexus for all three of those medical conditions. And so for that opinion, that opinion, even though you know it's it's crazy how those occur, that medical opinion states the veteran's chronic fatigue syndrome is at least as likely as not directly related to military service. And then in our rationale, we go on to discuss you know what the normal process for Epstein bar bar virus? Some people clear the Epstein bar virus, some people go on and never have issues, but for this individual, his body could not kick it.

SPEAKER_04: 1:00:49

So any questions?

SPEAKER_01: 1:00:54

That's the point to know. I mean, does everybody have mono, have Epstein bar virus or what?

SPEAKER_02: 1:01:03

So Epstein bar virus is what causes mono. So if you have a positive mono, then you have a positive Epstein bar bar virus in your in your system. Some people cleared out their immune system, fights off the Epstein bar virus and they don't see it. It's kind of like the chicken pox. So when you get the chicken pox, that virus stays around in your system unless your body kicks it out.

SPEAKER_01: 1:01:26

And if it doesn't, and you get to you get the shingles.

SPEAKER_02: 1:01:31

That's the same concept. So if your body, whether it's chronic stress, PTSD, something, um, cancer, that cancer lowers your immune system and all these virus viruses start to take off. But in this individual, it it blows my mind that he was able to tie a 2016 cancer to 1971 when he was deployed over in Germany. And the labs are there, the evidence is there, and that's what's consistent in the medical side of things. So we were able to help him with that.

SPEAKER_01: 1:02:05

Of course, now you get a lot of feedback.

SPEAKER_02: 1:02:10

We don't always we try to follow up with them. Um normally what we see happen is we'll get a surprise message on our website saying, Thank you so much, you've helped us so much. I appreciate it. Or sometimes we get um, hey, they denied me. Can you help me with a rebuttal? And then I get mad and I write a rebuttal and then we win the second time or whatever. So um we don't we used to seek, you know, trying to track those numbers, but in all honesty, you can't predict the VA. You can't predict what they're gonna do. Is it just like with with Secretary Shinseki, if we were running then and we were trying to keep stats on what we're doing then, he's like, oh, close all two-year or older claims, and then they just mass deny everybody. That's not reflective on us and what we do. Um, that's just the way the VA functions.

SPEAKER_01: 1:03:02

Yeah, well, that's how they get the numbers straight.

unknown: 1:03:05

Yeah.

SPEAKER_01: 1:03:05

Every time the cleaning process goes down on one end, it goes up on the other end. What comes around goes around. The BVA gets more, or the regal opposite has more. One goes up, one goes down. It's like a big yo-yo, and they go around the world for six years.

unknown: 1:03:25

Yeah.

SPEAKER_02: 1:03:28

I have to keep reminding myself, you know, why I do this because I get very frustrated at some of the the silly things that the VA comes back with. So I can't imagine it being my claim, or I just if if military isn't enough stress, you come home and you deal with the VA and it's stupidness, the stupid the stupidness of it.

SPEAKER_01: 1:03:55

Don't have PTSD. If you don't have the person anxiety of PTSD when you get out of service, just file a VA claim. And if it lasts long enough, you will have all three. You'll get it. I'm sorry.

SPEAKER_00: 1:04:12

That's very true. See it all the time.

SPEAKER_01: 1:04:18

Well, listen, kids, we're out of time. Uh, we'll do this again next month, uh December. What do you think about December? Wow, that's uh getting close to Christmas time and spending all that money time on the grandkids and buying gifts and stuff.

SPEAKER_02: 1:04:33

So I don't know where 2025 went. It's it's flown.

SPEAKER_01: 1:04:39

Yeah. Well, it's too much stuff happening in 2025. I mean, it there, you know, every day something happens, so you're pinned and you're looking at it. And when it happens, it's like occupy. We're talking today about a show. And like the faster the show goes, like it's like ratio, we it flew by, you know, because you know, the better the shows, the less, you know, the craft faster they go. Because you, you know, and uh so 25 was like a good show. I mean, it just zipped by real quick. So I don't know. We've been running ourselves like a bunch of chickens with her head cut off anyway this whole year. Healthy back and forth. Anyway, guys reviewed the show tonight. I want to make an announcement tonight, tomorrow morning is my 43rd wedding anniversary.

SPEAKER_03: 1:05:30

Congratulations.

SPEAKER_01: 1:05:34

This we're gonna have to be out uh try to do something really nice as far as uh you know food or whatever, and uh we'll see what happens. But uh 43 years is a long time.

SPEAKER_02: 1:05:49

But you look up I don't know how you do it. I don't know how she does it.

SPEAKER_00: 1:05:57

I feel sorry for his wife. You know, I don't feel sorry for him, but I feel sorry for her. Sweet lady.

SPEAKER_01: 1:06:06

All right, well, listen, guys. We'll see y'all next week. Uh you guys have a good weekend, and uh make sure Ohio State wins a football game Saturday and uh Tennessee. They're pretty decent. Sorry, Kentucky, you're out of luck, but and uh we'll be shutting her down for now.

SPEAKER_04: 1:06:23

We'll see everybody tonight.