2007 NVLSP 1 Letters to Medical Experts. 2007 NVLSP 2 Steps to Take Before Seeking a Medical Opinion Obtain a current diagnosis; Submit evidence that

2007 NVLSP2007 NVLSP 11

Letters to Medical ExpertsLetters to Medical Experts


Steps to Take Before Seeking a Steps to Take Before Seeking a Medical OpinionMedical Opinion

Obtain a current diagnosis;Obtain a current diagnosis;Submit evidence that shows it is possible (even better Submit evidence that shows it is possible (even better “as likely as not” or “more likely than not”) that the “as likely as not” or “more likely than not”) that the alleged in-service incident or event occurred;alleged in-service incident or event occurred;Research the current condition;Research the current condition;Interview the claimant/veteran and help the claimant Interview the claimant/veteran and help the claimant prepare a statement detailing the symptoms noted by the prepare a statement detailing the symptoms noted by the veteran that the advocate and the veteran believe are veteran that the advocate and the veteran believe are related to the current disability;related to the current disability;Interview family members and friends of the veteran who Interview family members and friends of the veteran who can provide additional lay statements regarding the can provide additional lay statements regarding the history of the veteran’s symptoms; history of the veteran’s symptoms; Obtain a copy of the veteran’s claims file;Obtain a copy of the veteran’s claims file;


Steps to Take Before Seeking a Steps to Take Before Seeking a Medical OpinionMedical Opinion

Prepare Cover Letter for Medical Expert — Prepare Cover Letter for Medical Expert — Letter Must:Letter Must:

explain the medical issue to resolve, explain the medical issue to resolve, note that a copy of the claims file is enclosed, note that a copy of the claims file is enclosed, summarize relevant facts and tab them in the C-file,summarize relevant facts and tab them in the C-file,ask medical expert to state that he/she reviewed C-file in their ask medical expert to state that he/she reviewed C-file in their response,response,stress that the standard of proof is the benefit of the doubt (as likely stress that the standard of proof is the benefit of the doubt (as likely as not) as not) ask detailed questions that usually can be answered with a yes or ask detailed questions that usually can be answered with a yes or no,no,invite medical expert to call you if any questions, andinvite medical expert to call you if any questions, and(if relevant) notify the medical expert where to send their bill(if relevant) notify the medical expert where to send their bill


Advocacy TipAdvocacy Tip

Make it easy for the medical expert to Make it easy for the medical expert to agree with the veteran’s contentions.agree with the veteran’s contentions.– Provide expert with continuity of Provide expert with continuity of

symptomatology (usually w/ lay statements)symptomatology (usually w/ lay statements)– Show expert medical texts and other Show expert medical texts and other

statements from experts that support linkage statements from experts that support linkage between the veteran’s current condition and between the veteran’s current condition and service service


Sample Letter to Medical ExpertSample Letter to Medical Expert

All letters should contain:All letters should contain:– OPENING PARAGRAPH--introduces veteran, gives OPENING PARAGRAPH--introduces veteran, gives

info on veteran’s condition, indicates why doctor info on veteran’s condition, indicates why doctor should provide a favorable medical opinion; should provide a favorable medical opinion; summarize standard of proof that is favorable to summarize standard of proof that is favorable to veteran.veteran.

– SUMMARY OF FACTS & LAW-- Give details of SUMMARY OF FACTS & LAW-- Give details of service; specify injuries/problems in service; service; specify injuries/problems in service; symptoms in service and post-service, treatment, symptoms in service and post-service, treatment, other medical opinions, and other relevant infoother medical opinions, and other relevant info

– QUESTION FOR EXPERT—be as precise as QUESTION FOR EXPERT—be as precise as possiblepossible

– CLOSING PARAGRAPH--thank expert, ask expert to CLOSING PARAGRAPH--thank expert, ask expert to indicate review of claims file, provide contact infoindicate review of claims file, provide contact info



Mr. Jones served July 1969 to January 1972Mr. Jones served July 1969 to January 1972 Wounded in action in 1971Wounded in action in 1971 Several times treated for painful feet. Bilateral foot complaints Several times treated for painful feet. Bilateral foot complaints variously diagnosed as: bilateral trench feet, bilateral pes cavus, variously diagnosed as: bilateral trench feet, bilateral pes cavus, bilateral pes planus. bilateral pes planus. Separation examination showed no musculoskeletal defects. Separation examination showed no musculoskeletal defects. Vet claims while in combat hurt his back several times, causing Vet claims while in combat hurt his back several times, causing significant pain. Did not seek treatment. significant pain. Did not seek treatment. After discharge, veteran had almost continuous pain in lower back, After discharge, veteran had almost continuous pain in lower back, still did not seek treatment. Lay statements from family say he is a still did not seek treatment. Lay statements from family say he is a stoic. stoic. In 1989, diagnosed with spinal stenosis. MRI provided impression In 1989, diagnosed with spinal stenosis. MRI provided impression of severe spinal stenosis. of severe spinal stenosis. In April 1989, Dr. Black indicated that vet had back problems for In April 1989, Dr. Black indicated that vet had back problems for years; in 8/88 developed significant pain. Veteran advised to years; in 8/88 developed significant pain. Veteran advised to consider surgery, but did not have surgery.consider surgery, but did not have surgery.



SUMMARIZE RELEVANT LAWSSUMMARIZE RELEVANT LAWS– Explain “benefit of the doubt” Explain “benefit of the doubt”

““Therefore, I will phrase my questions to you so that you can Therefore, I will phrase my questions to you so that you can respond to ‘Is it as likely as not.’”respond to ‘Is it as likely as not.’”

– Explain combat veteran advantageExplain combat veteran advantage““In Mr. Jones’s case, his statements about what happened to In Mr. Jones’s case, his statements about what happened to him during service all are connected to incidents that him during service all are connected to incidents that occurred when he was engaged in combat with the enemy. occurred when he was engaged in combat with the enemy. Therefore, for the purposes of your medical opinion, please Therefore, for the purposes of your medical opinion, please accept his statements as proven facts.”accept his statements as proven facts.”

– Explain that preexisting injury presumed to have been Explain that preexisting injury presumed to have been aggravated by service in cases where there is an increase in aggravated by service in cases where there is an increase in disability during service, unless specific finding that increase disability during service, unless specific finding that increase due to natural progress of disease.due to natural progress of disease.



QUESTIONS:QUESTIONS:– Is it as likely as not that current severe spinal stenosis is linked Is it as likely as not that current severe spinal stenosis is linked

to trauma suffered in service?to trauma suffered in service?– Assuming a preexisting back condition on entry (entry exam Assuming a preexisting back condition on entry (entry exam

noted limited lumbar motion & tenderness), is it as likely as not noted limited lumbar motion & tenderness), is it as likely as not that trauma to back in service, which resulted in increased back that trauma to back in service, which resulted in increased back symptoms, aggravated preexisting back condition, and that symptoms, aggravated preexisting back condition, and that back condition that was aggravated in service is linked to the back condition that was aggravated in service is linked to the current back condition?current back condition?

– SMRs show treatment for pain in feet, attributed in service to SMRs show treatment for pain in feet, attributed in service to pes cavus, pes planus, and trench foot. Is it as likely as not that pes cavus, pes planus, and trench foot. Is it as likely as not that bilateral foot pain is connected to the current back condition?bilateral foot pain is connected to the current back condition?

– Or, is it as likely as not that pain caused by SC trenchfoot Or, is it as likely as not that pain caused by SC trenchfoot caused or aggravated back condition?caused or aggravated back condition?



Thank doctor for assistance.Thank doctor for assistance.

Make clear doctor should indicate in letter Make clear doctor should indicate in letter that he/she reviewed the entire claims file.that he/she reviewed the entire claims file.

Provide contact information in case doctor Provide contact information in case doctor has questions. has questions.


Sample Letter 2 to Medical ExpertSample Letter 2 to Medical Expert

Begins by introducing the veteran, giving brief Begins by introducing the veteran, giving brief background of case, and why opinion background of case, and why opinion necessary. necessary. Opening includes paragraph that research Opening includes paragraph that research shows that those with mental illnesses more shows that those with mental illnesses more likely to smoke.likely to smoke.Letter introduces the doctor to “benefit of the Letter introduces the doctor to “benefit of the doubt” and low standard of proof.doubt” and low standard of proof.Make clear what Dr.’s opinion should contain:Make clear what Dr.’s opinion should contain:– statement that doctor reviewed entire c-filestatement that doctor reviewed entire c-file– Reasons or bases for the doctor’s conclusions Reasons or bases for the doctor’s conclusions



The letter also contains a “Cautionary Note.”The letter also contains a “Cautionary Note.”– ““Please focus only on the psychiatric condition for Please focus only on the psychiatric condition for

which the veteran was service-connected at the time which the veteran was service-connected at the time of his death and for the 47 years prior to his death—of his death and for the 47 years prior to his death—that is, that is, anxiety disorder with depression and anxiety disorder with depression and conversion symptoms. conversion symptoms. You said in one of your You said in one of your letters that he may have been misdiagnosed in the letters that he may have been misdiagnosed in the 1950s, and that his real service-connected condition 1950s, and that his real service-connected condition might more properly be characterized as PTSD. To might more properly be characterized as PTSD. To focus on a misdiagnosis that focus on a misdiagnosis that may havemay have occurred occurred about 50 years ago would probably do more harm about 50 years ago would probably do more harm than good to [the claimant’s] case at this point.” than good to [the claimant’s] case at this point.”



Vet served 1940-1945. In 1950, received SC for chronic Vet served 1940-1945. In 1950, received SC for chronic conversion reaction.conversion reaction.In 1977, he submitted documents showing he was In 1977, he submitted documents showing he was having trouble working. RO denied increased rating having trouble working. RO denied increased rating In 1993, vet stated he was worse and could not work. In 1993, vet stated he was worse and could not work. 1994 decision increased SC evaluation to 100% based 1994 decision increased SC evaluation to 100% based on TDIU, effective 10/93on TDIU, effective 10/933/96 RO decision awarded 100% schedular evaluation3/96 RO decision awarded 100% schedular evaluationVet died in 1996, due to chronic obstructive pulmonary Vet died in 1996, due to chronic obstructive pulmonary disease due to or as a consequence of “tobacco and disease due to or as a consequence of “tobacco and H[istory]/o[f] asbestosis.” Contributing causes were H[istory]/o[f] asbestosis.” Contributing causes were status post MI and status post 4-vessel bypass. status post MI and status post 4-vessel bypass. In 9/96, DIC application filed. In 9/96, DIC application filed.



Advocate asked Dr. the following question :Advocate asked Dr. the following question :– Is it as likely as not, or better, more likely than not, Is it as likely as not, or better, more likely than not,

that the veteran’s service-connected anxiety condition that the veteran’s service-connected anxiety condition causedcaused or aggravatedor aggravated (worsened) his smoking habit (worsened) his smoking habit (nicotine addiction). We already know from the death (nicotine addiction). We already know from the death certificate that COPD was determined to be the certificate that COPD was determined to be the primary cause of his death, and that “tobacco” was primary cause of his death, and that “tobacco” was considered a secondary cause. Please explain your considered a secondary cause. Please explain your answer. answer.

Advocate instructed Dr. to make her “own Advocate instructed Dr. to make her “own medical determination.” Thanked Dr. medical determination.” Thanked Dr.

Documents

2007 NVLSP 1 Letters to Medical Experts. 2007 NVLSP 2 Steps to Take Before Seeking a Medical Opinion Obtain a current diagnosis; Submit evidence that