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Information On Independent Medical Opinion IMO or IME Nexus Letters

Author: Craig Bash, MD

 

The IMO is an independent medical opinion and IME is a independent medical examination used for a claim for a Veterans Benefits Administration (VBA) disability compensation award which must be based on medical data. The IMO can be done without a hands on examination but the IME also uses the hands on process. The medical nexus (link- cause and effect- connection) letter can be either and IMO or IME.

The VA appeals process a few years back (1996) by court order eliminated their physicians on the board of the BVA and simultaneously added a requirement for a medical nexus by a physician to will ground a claim and this was the start of the IMO, IME and medical nexus process. Physicians know these letters as " Medical Opinion Letters AKA second opinion letters or clinical summary or clinical pathologic summary or forensic medical examination". The veteran needs a medial opinion letter done by a physician because the VA ratings are complicated and medical in nature and the rating is essentially a medical diagnostic code that is based on the veterans' military service. Without an supportive physician done medical opinion the patients case is really decided completely by the rater who is not a physician, does not know the patient and who works for the VA and is thus under administrative VA pressure to decide cases at a certain rate and often meet interval rating guidelines. Some of these IMO and IME are starting to be done by physician assistants and nurse practitioners as a way to save money but on regional office review or appeal these non-VA non-physician opinions are routinely discounted because the VA will simple obtain an additional physician opinion to clarify the issues and of course the physician opinion eclipses any non-physician opinion (please see at the bottom of the review a comparison of credentials for an average physician vs the average non-physician). A good physician medical opinion will also identify all secondary conditions that might stem form the original VA service related problem which is often not done by a non-physician because they simply do not have the depth of knowledge to make these integrative inferences concerning the veterans complex medical problems that evolve over decades. The physician can also order additional tests as needed to identify all diagnoses and secondary conditions.

The medical opinion letters are difficult for the physician to write because these letters are usually contain both medical and administrative content and the administrative content often increases the physicians risk for being deposed and/or ask to appear before a court hearing judge which is the last thing a practicing clinical physician wants to do. The VA on the other hand has 14,000+ physicians that can be asked for opinion letters and the VA is also able to use QTC physician network for opinions thus the VA is able to get many medical opinions to evaluate the pending medical issue. It is important to note that often if the VA asks any physician a very narrow specific clinical question pertaining to a veteran's claim that the answer to that question can be swayed based on the specific narrow question asked. For example, if the VA asks the physician the following question "Does this patient's aortic valve disease related to his service?" The physician would look at the c-file and see that the patient did not have aortic value disease and the answer correctly would be no and the veterans would lose benefits. But if the VA instead asks this question "Is this patient's heart disease related to service?" The physician would again look at the c-file and see that the patient had long-standing hypertension since service with current hypertension induced cardiac disease and the answer would correctly be yes and the patient would be awarded benefits.

It is important to note that the VA rating codes are very general medical categories of disease thus there is a lot of medical administrative judgment involved in the development and assignment of these codes therefore many conditions can be rated under several different/analogous codes.

It is therefore very important for the medical opinion physician to know the VA rules/categories and VA rating schedule prior to doing any opinions because the knowledgeable physician is able provide a nexus opinion that establishes all of the correct diagnosis and provides appropriate links to that diagnosis in service.

All veterans should have a medical opinion that is done by a physician who knows the VA rules and who has done several VA opinions. The ideal knowledgeable physician should also have experience with several hundred VA medical opinions and/or personal experience with the complicated VA rating process so that he has knowledge of the regional office, decision review officer, BVA and CVA appeals process and an understanding of concepts such as: special monthly compensation, preexisting such service, was aggravated, analogous rating, staged rating, pyramiding of claims, common etiology and individual unemployability (TDIU).

Often the VA requires second, third and forth clarification opinion letters which are often spread out over 3-5 years due to the large VA backlog of claims and thus the ideal knowledgeable physician should have at least 5 years experience in writing VA opinions in order to know the full spectrum of the process. Of course the ideal physician would have had prior military experience so that he is familiar with the inherent risks of military training/combat and that he is familiar with the lack of medical specialty care available in the field and at the remote world wide locations and that he is familiar with incomplete/missing medical records and that he is familiar the inability of physicians to access on line medical information. For example, recent research shows a significant inability of physicians to access the medical literature/resources as only "… 19% of physicians had daily access to the Internet while deployed…" ( Ref: Kane, et. al. Military Medical informatics: Accessing Information in the deployed environment Military Medicine vol.176, no. 3, p. 259 March 2009).

Additionally, all opinions should include the following:

Review of claims file, all medical records, all imaging reports and all laboratory reports.
Medical examination if the VA or QTC physician has done a medical examination.
A dedicated section-by-section SOAP note/clinical pathologic summary oriented review of each VA ratable condition to include all secondary complications.
An analysis of potential confounding factors such as other disease processes, other intervening injuries and familial diseases.
An analysis of medications taking to ameliorate the service connected conditions and possible secondary drug induced disease processes.
An analysis of potential ratings situations such as special monthly compensation, preexisting conditions, and aggravated conditions, analogous rating, staged rating, common etiology, individual unemployability (TDIU).
Ordering of any additional tests as needed to identify all diagnoses and secondary conditions.
Incorporate all the patient's lay/buddy statements.
Literature references.
Listing of credentials.
Use of the following probability terms because the VA will grant VA benefits if the probability of an association between two events or causation of an event it at the as likely as not level of confidence (50%):

"is due to/caused by" = 100% sure/caused by
"more likely than not" = greater than 50%
"much more likely than not" = greater than 75% level of certainty
"very likely" = greater than 90% level of certainty
"at least as likely as not" consistent with reasonable doubt = equal to or greater than 50%
"not at least as likely as not" = less than 50%
"is not due to" = 0%

Rationale for nexus/causation opinions based on the medical literature, the medical records/claims file, standard medical principles and the physician's experience /training.
An analysis of all other medical opinions contained in the claims file and an assessment of their merits concerning the service connection or potential to be service connected.

___________________________________________________________________
Comparison of credentials for an average physician vs the average non-physician

Physician PA/nurse-practitioner
College/University 4 years 2-4 years
Medical school MD degree 4 years none
Licensed Physician Yes no
Nurse school/PA none 2-3 years
Internship/OJT 1 year none-1
Residency 4 years none
Fellowship clinical 1 year none
Practice only under supervision No Yes- Required
Peer reviewed articles yes ?
Paper H-index 15 ?
Several hundred VA IME's yes ?
Years experience as MD 20+ none
Review x-ray/CT/MRI if available yes not able to
Number of years doing VA cases 5 ?

 
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