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(cell phone 240-506-1556)

To: All veterans

Date: Dec 2014


Permanent and Total

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)
Pages: 2

Craig N. Bash, M.D.


NPI or UPIN-1225123318- lic #--D43471

4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589

The high percentage medical diagnostic rating code levels to include Permanent and Total (PT) are
expensive to fund by the VA and are both very complex medically and administratively and thus often
involve several appeal stages. Since the VA only grants 30-50% of the correct rating on each
iteration (not considering SMC codes) a typical example of the step wise iterative grant of ratings is
as follows:

ON APPEAL (this could as many as three appeals)

20-30% rating
100% PT

As you can see from above the VA usually grants the 100% at the temporary level and not at the PT level
as part this is part of their culture of a minimalist approach to claim medical diagnostic codes rates. (n.b.
I have only seen one time a claim go from an initial claim to a SMC/R-1 level of grant in one iteration.)
Furthermore, as the rating become assigned to the highest code percentages (100%+ and SMC) the
regional offices will push these claims to the BVA (Board of veterans affairs) to decide. The BVA has a
staff of about 100 Admin law judges with support staff of about 2-300 more lawyers. Based on my 500
cases at the BVA it is my opinion that at this level the decisions are well thought out but even these
decisions are only validated at 30-40% level by the supervisory VA court. The above process could take
5 years or more for an initial valid PT case to make its way from the RO (regional office) and be decided
at the BVA. Thus any new lawyer, physician or advocate expert needs about 15 years of experience to
fully understand the ins and outs of this RO to BVA decision process because of the 5 year time lag in
decisions. Any new advocate needs many BVA iterations of different types of PT claim decisions to have
an expert knowledge of the BVA. A PT claims 5 years could be consumed as follows depending on RO:
Initial Claim process
10% to 50% appeals
50% to 100%-temporary
100% to PT hearing
100% PT decision

Time in route
6-12 months at RO
12-18 month at RO
12-18 months at RO
12-18 months for BVA hearing appointment
6-12 months at BVA

** I expect with the 2014 secretary McDonalds reforms, that many of the above times will be cut by 50%.
In the final analysis, the PT decision hinges on the medical analysis of the medical condition in an
independent veteran medical opinion. Each non VA medical code, of which there are about 65,000
ICD-9 codes, is boiled down to about 2000+ codes in the VA system. Each code has a different natural
history and a different permanent end stage disease status. Physicians who write veteran medical
opinions should be able to categorize all disease states into the VAs directory of only 2000+ codes,
which is not a trivial process as the VA codes all have different combinable aspects, which of course
excludes pyramiding of codes.
In my experience, most medical processes that have been present for 24 months with medical treatment
and no improvement are all permanent processes and thus should be assigned the PT code. Thus, most
veterans who migrate thru the above 5-year process with unchanging medical conditions meet my 2 year
rule and should be assigned PT, but VA will assign many of these a temporary code with the requirement
for a re-examination in 24-36 months - as that is their philosophy.
The PT code is an important addition to the 100% code as is eliminates the need for a future examination
and allows veterans extra benefits such as elimination of many state/country property taxes and
child/spouse benefits. (It should be remembered that all ratings even the PT and rates are not
administratively unchanged until they have been in place for 20 years.)
1. All veterans with large PT medical diagnostic combined codes should seek advocates that have 15 plus
years advocating at the BVA level so that they know the BVA review process as moist substantial claims
eventually make their way to the BVA.
2. Like wise all veterans should seek physicians who have 15+ years of independent veteran medical
opinions at the BVA level as the VA medical diagnostic code process is complex with multiple layers of
Additionally, all physicians who write Veteran Medical Opinions [Independent Veteran Medical Opinion
(IMO)-Veteran Medical Nexus Opinion (VMNO)] should be able to categorize Non VA PT type codes
into the VAs directory of only 2000+ codes. This is not a trivial process, as the VA codes all have
different a complex combinable aspects, which pf course excludes pyramiding of codes.
3. Low levels of training and experience by either physicians or advocates hurts a veterans chances of
getting a correct PT medical diagnostic code as any mistake made at the lower levels of appeals are
magnified under further appeal reviews and amount of needed extra time, medical testing, medical
opinions and associated paperwork to try and correct early errors is substantial and a correction is not
always possible.
Craig Bash M.D. Associate Professor cell 240-506-1556

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)
based on Veterans medical records