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Asthma


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17 replies to this topic

#1 Vync

 
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Posted 17 December 2009 - 08:32 PM

Please review my logic regarding an increase in SC rating. I am currently SC (6602) 10% for asthma bronchiole and would like to increase it above 10%.



Here is a snippet from 4.97 - Schedule of ratings - respiratory system

6602 Asthma, bronchial

FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications
100 %

FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids
60 %

FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication
30 %

FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy
10 %

Note: In the absence of clinical findings of asthma at time of examination, a verified history of asthmatic attacks must be of record.




Here are the corticosteroid I was prescribed in my medical records
2009-12-16 Aristospan corticosteroid (Non-VA, for lumbar epidural injection)
2009-12-11 Asmanex 220 mcg - Mometasone furoate corticosteroid inhaler (VA)
2009-12-11 Nasonex 50 mcg - Mometasone furoate corticosteroid nasal spray (VA)
2009-11-03 Aristospan corticosteroid (Non-VA, for lumbar epidural injection)
2009-10-23 Asmanex 220 mcg - Mometasone furoate corticosteroid inhaler (VA)
2009-09-03 Asmanex 220 mcg - Mometasone furoate corticosteroid inhaler (VA)
2009-09-03 Prednisone corticosteroid (VA) *** 1 ***
2009-08-28 Nasonex 50 mcg - Mometasone furoate corticosteroid nasal spray (VA)
2009-04-07 Nasonex 50 mcg - Mometasone furoate corticosteroid nasal spray (VA)
2009-02-13 Nasonex 50 mcg - Mometasone furoate corticosteroid nasal spray (VA)
2009-01-15 Prednisone corticosteroid (VA) *** 2 ***
2009-01-06 Medrol corticosteroid (Non-VA) *** 3 ***

2008-12-01 Decadron corticosteroid (Non-VA)
2008-10-02 Prednisone corticosteroid (VA)
2008-09-10 Decadron corticosteroid (Non-VA)
2007-11-09 Prednisone corticosteroid (VA)
2005-05-24 Prednisone corticosteroid (VA)
2002-03-27 Prednisone corticosteroid (VA)

Note: I was prescribed Prednisone and Medrol corticosteroids orally three times within the last 12 months.

I also take a Singulair pill and a puff from my Albuterol inhaler daily.

Regarding Mometasone Furoate
The Asmanex 220 mcg instructions say to inhale once daily at bedtime.
The Nasonex 50 mcg instructions say to spray twice in both nostrils twice daily.

Inhaled
220 mcg

Nasal
50 mcg x 2 sprays x 2 nostrils x 2 times per day = 400 mcg

I'm getting 620 mcg of this stuff per day!


Without taking my Albuterol inhaler, I can blow about a 350-400 l/min on my peak flow meter. For my age (38) and height (68"), I should be normally pushing about 650 l/min, placing my lung capacity at about 54-61% of normal. If I take my Albuterol inhaler, things improve a good bit.


Please review and offer your recommendation as to the appropriate SC percentage.

Edited by Vync, 17 December 2009 - 09:01 PM.


#2 JamesBreckenridge

 
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Posted 17 December 2009 - 08:59 PM

I'd prolly grant 30 on your puffer medications, or possibly higher based on your pulmonary function tests depending on your FEV1 or FEV1/FVC ratio, post-bronchiodialator (which is the measurement that counts).

Don't try and fake the pulmonary function tests. The doctors know, and they put things like "suboptimal effort" or "results not reliable."

#3 Vync

 
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Posted 17 December 2009 - 09:07 PM

I'd prolly grant 30 on your puffer medications, or possibly higher based on your pulmonary function tests depending on your FEV1 or FEV1/FVC ratio, post-bronchiodialator (which is the measurement that counts).

Don't try and fake the pulmonary function tests. The doctors know, and they put things like "suboptimal effort" or "results not reliable."


JB,
That's why I noted the "or's" in bold. I know not to fake the PFT's. I have not had any PFT's in a while, but they did give me a free peak flow meter. Generally, when I test three times, the l/min each successive attempt reduces by 15-20%. I'm usually out of breath in three or four attempts.

I have a long history of asthma and exercise induced asthma. Big stack of papers and tests from the Army. I am currently being treated by my VA allergist, who has done a heck of a better job than anyone else.

#4 JamesBreckenridge

 
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Posted 17 December 2009 - 09:11 PM

JB,
That's why I noted the "or's" in bold. I know not to fake the PFT's. I have not had any PFT's in a while, but they did give me a free peak flow meter. Generally, when I test three times, the l/min each successive attempt reduces by 15-20%. I'm usually out of breath in three or four attempts.

I have a long history of asthma and exercise induced asthma. Big stack of papers and tests from the Army. I am currently being treated by my VA allergist, who has done a heck of a better job than anyone else.


I'd file a claim TOMORROW with numbers like that, if it's a claim for increase.

#5 Vync

 
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Posted 17 December 2009 - 09:21 PM

I'd file a claim TOMORROW with numbers like that, if it's a claim for increase.


Would I just fill out the regular claim form and then attach copies of my prescription lists from the VA and Wal-mart?

I know the VA has the doctor's Allergy exam notes in their computer (just got them about a week ago). Should I put together a list (like I did for the meds) of my recent doc visits?

I am beginning to recall the prednisone/medrol being given for something other than asthma (which actually helped my asthma too), but regardless, they got my on some strong inhaled/nasaled steroids which should warrant an increase anyhow.

What do you think?

#6 Teac

 
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Posted 17 December 2009 - 09:54 PM

I think you are entitled to an increase to at least 60% based on what you stated. Keep in mind when the va is talking about asthma and steriods they are talking about steriod pills or shots prescribed for the asthma only. Any other steriod ( ie back injury) will not qualify. Also the va is more likely to rate based on the PFT and in reality a rating based on a PFT would be more permanent than a rating based on steriod use, unless steriod use is constant.

#7 jbasser

 
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Posted 17 December 2009 - 09:58 PM

Fill out a 21-4138 ask for increase and state the medications and attach the evidence you have.

You should be OK according to your numbers.

They may give you a PFT anyway.

J

#8 Teac

 
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Posted 17 December 2009 - 10:00 PM

Would I just fill out the regular claim form and then attach copies of my prescription lists from the VA and Wal-mart?

Just write a letter and include the prescription list as well doctor treatment notes should also be submitted as evidence.

I know the VA has the doctor's Allergy exam notes in their computer (just got them about a week ago). Should I put together a list (like I did for the meds) of my recent doc visits?

You could but it is not necessary

I am beginning to recall the prednisone/medrol being given for something other than asthma (which actually helped my asthma too), but regardless, they got my on some strong inhaled/nasaled steroids which should warrant an increase anyhow.

Unless the steriods were prescribed for the asthma they will not help your case... I am asthmatic with COPD, rated 100% just for my lungs, so I know what your saying as far as the steriods helping the asthma but the va will likely refuse an increased in rating because you have to prove that the asthma has gotten worse and it required the steriods. From what your now saying the asthma was not treated with steriods. Best of luck but I now think you will not get an increase. Also, Nasal administerd steriods or inhaled steriods are not oral or parential and will not help qualify for an increased rating.

What do you think?


Edited by Teac, 17 December 2009 - 10:05 PM.


#9 Vync

 
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Posted 17 December 2009 - 10:10 PM

The Asmanex daily inhaled steroid was prescribed for my asthma on 2009-09-03, a bit more than three months ago, so I would definitely consider this daily use. I will need to research the purpose of the prednisone and medrol. Usually, they give it to me in conjunction with antibiotics to help clear up my sinuses. However, a few weeks after the treatment, it's all stopped up again. It used to be a lot worse without the nasonex.

#10 akwidow

 
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Posted 17 December 2009 - 10:44 PM

hmmm. My late husband filed for asthma in 2000 and was denied. They said he didn't have enough history to make it sc. they looked at two years of THEIR treatment to him, when there was SMR's back to 1968 in their records, along wth private records that they gave me when I asked. He was hospitalized about 8 times in between heavy medication treatments....

He didn't challenge it. I found CUE in his case.

You keep on them!

#11 Teac

 
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Posted 18 December 2009 - 01:15 AM

The Asmanex daily inhaled steroid was prescribed for my asthma on 2009-09-03, a bit more than three months ago, so I would definitely consider this daily use. I will need to research the purpose of the prednisone and medrol. Usually, they give it to me in conjunction with antibiotics to help clear up my sinuses. However, a few weeks after the treatment, it's all stopped up again. It used to be a lot worse without the nasonex.


Let me clearify what I ment when I said inhaled steriods do not help an award, because that was not entirelly true. What I should have said was that only oral steriods (pills) or parenteral steriods (shots) are considered for the 60 or 100% award.

While any inhalational (steriod or not) or oral bronchodilator qualifies for the 30% award....



but the medication must be prescribed because of the asthma, a steriod medication prescribed for sinusitis, or back injury will not help you asthma claim.

#12 carlie

 
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Posted 18 December 2009 - 06:08 AM

Vync,
Prednisone and a Medrol dose pack are the same thing.
The Medrol, to my knowledge is just a handy,tirated (sp) package.
Example:
Day 1 = 6 pills
Day 2 = 5 pills
Day 3 = 4 pills
Day 4 = 3 pills
etc...
jmho,
carlie

#13 Vync

 
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Posted 18 December 2009 - 08:17 AM

Carlie,
Yes, I am very familiar with prednisone. It makes me hungry and irritable as it tapers off.

Teac/Carlie,
The VA gives me immunotherapy (IT, a.k.a. allergy shots) and have for years. Here's the doctor's entry regarding adding the Asmanex inhaler. I have an extremely long history of asthma and allergy treatments with the VA. It even dates back to 1991 in the Army. Big paper trail. I hope this entry sheds some additional light to the situation.


PROBLEMS:
1. Asthma
2. Allergic Rhinitis

CURRENT RESPIRATORY MEDICATIONS:
1. Albuterol metered odse inhaler as needed
2. Singulair 10 mg every day
3. Opticrom drops as needed
4. Nasonex
5. Immunotherapy

HISTORY OF PRESENT ILLNESS:
The patient returns having had a couple recent exacerbations of his asthma and sinus symptoms. 5-6 weeks ago was seen by outside doctor who noted sinus infection (by sinus film) and asthma exacerbation. He was placed on bactrim and prednisone shot, with some relief, but symptoms soon returned and saw {VA Doctor} who offered 7 day course of augmentin; Symptoms completely resolved.

Today, he reports 3-4 days of returning symptoms: increased cough (productive of scant yellow sputum, albuterol use BID, with sinus congestion and white-yellow drainage.

Otherwise, he continues to use his albuterol for exercise with benefit, and continues to report satisfaction with nasonex, claritin and singulair.

PHYSICAL EXAMINATION:
He is alert, in no distress, good mood, normotensive, afebrile. Canals are clear. Tympanic membranses intact. Conjunctivae and sclarae. Nasopharyngeal mucosa with bilaterally enlarged turbinates with white/yellow drainage. Chest with expiratory wheeze.

DATA:
Peak flow historic best 550
Peak flow pre bronchodilator 425
Peak flow post bronchodilator 425 (unchanged)

IMPRESSION:
1. Asthma with acute exacerbation. Suspect etiology 2/2 viral illness having already cleared previous infection. Given recent episodes of exacerbation, will add another controller medicine.

2. Viral URI/ acute sinusitis

3. Chronic allergic rhinitis

PLAN:
1. Continue nasonex
2. Hold IT today
3. Short prednisone buest 30/30/20/20/10/10
4. Add mometasone 22mcg QHD (for improved control)
5. Continue albuterol PRM, and before exercise. Continue singulair and nasonex.
6. Sinus rinse prm
7. I would like to see him in one month. If improved, can resume IT.


This shows
- The steroid inhalers were prescribed for "improved control" of my asthma.
- Also, the doc indicated "bilaterally enlarged turbinates" (see below).

Enlarged turbinates
Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, as the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

I am hoping for a good chance for the 30% SC award for increase in asthma. Also, I have a sleep study coming in February for OSA. If they say I have OSA, then it is likely because of the enlarge turbinates, which could hopefully be connected secondary to my SC rhinitis... Good to have these notes in the record. Also, my girlfriend said I woke her up last night a couple of times with my loud snoring.

Thanks!

Edited by Vync, 18 December 2009 - 08:19 AM.


#14 carlie

 
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Posted 18 December 2009 - 08:29 AM

[/b]I am hoping for a good chance for the 30% SC award for increase in asthma. Also, I have a sleep study coming in February for OSA. If they say I have OSA, then it is likely because of the enlarge turbinates, which could hopefully be connected secondary to my SC rhinitis... Good to have these notes in the record. Also, my girlfriend said I woke her up last night a couple of times with my loud snoring.

Thanks!


Vync,
I can see a probable increase in asthma to 30%.
A future claim as "secondary to my SC rhinitis"
the "enlarge turbinates" might be
denied as pyramiding, so check that out.
jmho,
carlie

#15 Vync

 
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Posted 18 December 2009 - 08:45 AM

Vync,
I can see a probable increase in asthma to 30%.
A future claim as "secondary to my SC rhinitis"
the "enlarge turbinates" might be
denied as pyramiding, so check that out.
jmho,
carlie


No, I am looking to increase my asthma to 30% because I meet the qualifications based on daily inhaled steroids.

If the sleep apnea is diagnosed, I will be seeking it secondary to my rhinitis, due to the enlarged turbinates/limited sinus airway.

Thus, I hope that this will not be considered pyramiding, as they are two completely separate conditions.

#16 ArmyTexas

 
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Posted 18 December 2009 - 12:49 PM

It should be a problem to get at least 30% from the meds alone. I''ve been on Advair 500/50 discus for 4 years. It's one of the most common prescribed bronchial-dialators and that automatically gets you 30%. With the way my PFT's are and 4-5 courses of prednisone I'm at 60%.

With your Prednisone use, check you doctors notes and highlight why it was prescribed. 3 courses or more a year is 60%. The only way to prove it was for the Asthma is thru the notes, unless the doc writes a statement of the dates you were prescribed for Asthma. If your not seeing a Pulmary doc, try to find one. Most really know their stuff and are better than a Primary care.

Hope everything works out for you, especially your health, Asthma problems sneek up on you.

#17 Vync

 
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Posted 17 January 2010 - 11:00 AM

Hello everyone,
Several questions are at the end, but I think I finally have everything together regarding my request to increase SC rating for asthma.

I wrote a cover page which ties all the facts together. All records are from the VA and pertain solely to my asthma treatment. All key information is highlighted, for ease of verification. I realize all of this information is in my VA treatment records, which they can review at will, but I do not want to take any chance that they will miss anything.

For increase to 30%:
- Mometasone furoate prescribed for daily use five months ago

For increase to 60%:
- Two instances where oral prednisone was prescribed
- One instance where IV solumedrol (liquid prednisone) was administered
- All occurred within the last five months

Additional Information:
- Prescription refill history showing asthma medications back to my EED in 1995 (various inhalers, singulair, etc...)
- Last month, I was issued a nebulizer plus albuterol solution for home use
- VA treatment record and letter excusing me from work for almost two weeks last month, due to adverse reaction to high doses of steroids within a short period of time
- VA rating schedule for asthma
- Several BVA reference cases where SC was granted 60% because oral steroids were prescribed for asthma 3+ times within 12 months.


Questions:
1. With evidence that clearly shows I meet the requirements for both 30% and 60%, should I even bother to get an IMO/nexus letter? This is a SC increase request, not an initial SC request.

2. Do I need to write a personal statement describing the worsening of my condition and its impact on my life and work?

3. Do you think they will request a C&P exam or just use the evidence in my records to grant an SC increase? I am not requesting the increase based on FEV reduction, so going in to see a doc seems useless, because my records speak for themselves.

4. Regarding the EED, should I ask for an EED of 30% between the time when I met the 30% requirement and the time I met the 60% requirement? Or should I get SC first, then argue for an EED change afterwards? It seems to make more sense to ask for SC and an EED adjustment at the same time, because it would be less work for me and the VA.

5. Am I missing anything or is there anything else I could do to strengthen my claim?

6. My last question is regarding the SC rating math, if my request is granted. If my asthma rating changes from 10% to 30%, then 30, 20, 10, 10 = 54.64%. Would this round down to 50% or would they round 54.64% to 55%, then round 55% up to 60%?

#18 ArmyTexas

 
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Posted 18 January 2010 - 07:16 AM

Hello everyone,
Several questions are at the end, but I think I finally have everything together regarding my request to increase SC rating for asthma.

I wrote a cover page which ties all the facts together. All records are from the VA and pertain solely to my asthma treatment. All key information is highlighted, for ease of verification. I realize all of this information is in my VA treatment records, which they can review at will, but I do not want to take any chance that they will miss anything.

For increase to 30%:
- Mometasone furoate prescribed for daily use five months ago

For increase to 60%:
- Two instances where oral prednisone was prescribed
- One instance where IV solumedrol (liquid prednisone) was administered
- All occurred within the last five months

Additional Information:
- Prescription refill history showing asthma medications back to my EED in 1995 (various inhalers, singulair, etc...)
- Last month, I was issued a nebulizer plus albuterol solution for home use
- VA treatment record and letter excusing me from work for almost two weeks last month, due to adverse reaction to high doses of steroids within a short period of time
- VA rating schedule for asthma
- Several BVA reference cases where SC was granted 60% because oral steroids were prescribed for asthma 3+ times within 12 months.


Questions:
1. With evidence that clearly shows I meet the requirements for both 30% and 60%, should I even bother to get an IMO/nexus letter? This is a SC increase request, not an initial SC request.
Shouldn't need an IMO, just the records from treating doc should be fine.
2. Do I need to write a personal statement describing the worsening of my condition and its impact on my life and work?
You can, If you mention struggling at work or missing a lot of time, VA may infer IU-They did with me (I'm still working though so I know this one will get denied)
3. Do you think they will request a C&P exam or just use the evidence in my records to grant an SC increase? I am not requesting the increase based on FEV reduction, so going in to see a doc seems useless, because my records speak for themselves.
They will definately call you in for a C&P-They will do a current PFT-They did with me.
4. Regarding the EED, should I ask for an EED of 30% between the time when I met the 30% requirement and the time I met the 60% requirement? Or should I get SC first, then argue for an EED change afterwards? It seems to make more sense to ask for SC and an EED adjustment at the same time, because it would be less work for me and the VA.

5. Am I missing anything or is there anything else I could do to strengthen my claim?
Have your doc tie the steriods to the Asthma so that that there it can't be linked to the sinus. When you go to the C&P. Hand carry the med list. Call Respitory before the PFT to see about taking meds that morning. They called me a week prior and let me know to not take my morning Asthma meds unless in distress.
6. My last question is regarding the SC rating math, if my request is granted. If my asthma rating changes from 10% to 30%, then 30, 20, 10, 10 = 54.64%. Would this round down to 50% or would they round 54.64% to 55%, then round 55% up to 60%?



You are going to get at least 30% and maybe 60% initially. File a NOD for the 60% if you don't get it.

When I received my 60% for Asthma, they listed the evidence as low PFT's and 4 courses of oral steriods, so I know that they look at the meds to consider.

Good luck on your claim.