PTSD Compensation and Military Service (2007) / Chapter Skim
Currently Skimming:
5 The Evaluation of PTSD Disability Claims
5 The Evaluation of PTSD Disability Claims
Pages 113-164
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 113... ...
The Department of Defense Disability Evaluation System The core functions of the DOD DES are to ensure that the military force remains fit and to provide compensation for those service members on regular active duty, in the Reserve, or in the National Guard whose military careers are cut short by illness or injury before they meet time-in-service requirements for retirement benefits eligibility. DOD disability benefits are
|
From page 114... ...
5-2) VHA Physical for Disability Evaluation VA VASRD Rating FIGURE 5-1 Military disability compensation pathways.
|
From page 115... ...
. The standard for the determination of DOD disability ratings -- DOD Instruction 1332.39; Title 10, United States Code Chapter 61 -- is the Department of Veterans Affairs' Schedule for Rating Disabilities (VASRD)
|
From page 116... ...
Of the four components, VA administers two: the Disabled Transition Assistance Program (DTAP) , which offers briefings about the VA's vocational rehabilitation programs, and Benefits Delivery at Discharge (BDD)
|
From page 117... ...
. Disabled Transition Assistance Program and Benefits Delivery at Discharge The VA has two separate programs that allow personnel to initiate disability claims while still on active duty.
|
From page 118... ...
. No matter what disability rating has been determined by the DOD, if a veteran desires compensation from VA, he or she must submit a separate application for disability benefits and have the VA rate their condition all over again.
|
From page 119... ...
Post-Determination Team Develops nonrating end products, Appeals to promulgates ratings, prepares higher courts notification letters, completes nonrated Veteran/Dependent entitlement determinations Notified Indicates non-appeal processing Indicates appeal processing FIGURE 5-2 Veterans Benefits Administration Claims Process (CPI model)
|
From page 120... ...
.7 Beyond the management of incoming mail and related files, the triage team is authorized to process those claims requiring only minimal review of the evidence. The VBA M21-1MR does not provide details on what is considered to be a "minimal review." The predetermination team manages claims requiring administrative decisions and determines when a claim is ready for a decision or rating.
|
From page 121... ...
The appeals team -- coach, decision review officer, senior VSR, RVSR, VSR, claims assistant, and file clerk/program clerk -- oversees this process, which consists of several stages.9 Initially, if a claim is denied or a veteran disagrees with the level of the disability level awarded, she or he files a notice of disagreement. The claimant is then contacted by a Decision Review Officer (DRO)
|
From page 122... ...
The VA disability rating depends on a complex assessment of many factors, and numerous variables play a role in determining the amount of the disability awarded. The VASRD does not take into account military rank, tenure, sex, or wartime cohort.
|
From page 123... ...
The VA Inspector General's 2005 review of state variances in disability compensation payments found that mental disorders -- including PTSD -- had the fourth highest variability in disability rating of the 15 body systems (DVA, 2005b)
|
From page 124... ...
A 2005 survey of VBA rating-team members by the VA Office of the Inspector General found that the two greatest issues in the rating process were, in order, the "perceived emphasis on production at the expense of quality" and "the need for more and better training" (OIG, 2005, p.
|
From page 125... ...
. ISSUES REGARDING PTSD DISABILITY RATING CRITERIA VA asked the committee to address several issues related to the rating criteria currently used to rate disability for veterans with service-connected PTSD.
|
From page 126... ...
TABLE 5-2 VASRD Disability Percentage Ratings for Selected Conditions Condition 10% 20-30% 40-50% 60-70% 100% Mental disorders OSIa due to 30 OSI with decrease 50 OSI with 70 OSI, with major Total OSI, due to such mild or transient in work efficiency reduced deficiencies in symptoms as: gross symptoms which and intermittent productivity most areas, such impairment in thought; decrease work occupational due to such as work, school, persistent delusions efficiency and impairment due symptoms as: family, judg- or hallucinations; ability to perform to such symptoms flattened affect; ment, thinking, grossly inappropriate occupational as depressed disordered or mood, due to behavior; persistent tasks only mood; anxiety; speech; such symptoms as danger of hurting self during periods of suspiciousness; panic attacks suicidal ideation; or others; intermittent significant stress; panic attacks obsessional inability to perform ≥ once a week; or symptoms (weekly or less impaired rituals; disordered ADL; disorientation to controlled by often) ; memory and speech; near- person/time/place continuous chronic sleep judgment; continuous panic medication impairment; mild disturbed or depression memory loss motivation and affecting ability to mood; difficulty function; impaired in establishing impulse control; and maintaining neglect of personal relationships appearance; etc.
|
From page 127... ...
Loss of auricle Deformity of one, 30 Complete loss of 50 Complete loss one of both with loss of ≥ 1/3 Chronic fatigue Waxes and wanes, 20 Nearly constant 40 Nearly constant 60 Nearly constant Nearly constant and syndromeb resulting in periods and restricts and restricts and restricts so severe as to restrict of incapacitation routine daily routine daily routine daily routine daily activities activities by < activities to activities to < almost completely and of ≥ 1 (< 2) wk/yr 25% of pre-illness 50 to 75% 50% of pre- which may occasionally level; or which of pre-illness illness level, or; preclude self-care waxes and wanes, level; or which which waxes and resulting in periods waxes and wanes, resulting of incapacitation wanes, resulting in periods of in periods of of ≥ 2 (< 4)
|
From page 128... ...
; or minimum rating and progressive weight limitations minimum rating with AIDS loss, with few or no with T4 < 200, remissions or hairy cell leukoplakia, or oral candidiasis Sinusitisb 1-2 incapacitat- 30 50 Following ≥ 3 incapacita ing episodes/yr ting episodes per radical surgery requiring year requiring with chronic prolonged (4-6 prolonged (4-6 osteomyelitis; wks) antibiotics; wks)
|
From page 129... ...
left ventricular ejection fraction of 30-50% continued
|
From page 130... ...
TABLE 5-2 Continued 0 Condition 10% 20-30% 40-50% 60-70% 100% Supraventricular Permanent atrial 30 Paroxysmal atrial arrhythmias fibrillation; or fibrillation or other 1-4 episodes/yr of supraventricular paroxysmal atrial tachycardia, with > fibrillation or other 4 four episodes/yr supra-ventricular tachycardia Hypertensiond Diastolic pressure 20 Diastolic pressure 40 Diastolic 60 Diastolic pressure predominantly predominantly pressure predominantly 100 or more, or 110 or more, or predominantly 130 or more systolic pressure systolic pressure 120 or more predominantly predominantly 200 160 or more, or or more requires contin uous medication for control Varicose veins Intermittent 20 Chronic edema, 40 Chronic edema 60 Chronic edema Massive board-like edema/symptom incompletely and stasis or stasis change edema with constant relief via elevation relieved by changes and persistent rest pain or compression elevation of legs ulceration hose Irritable bowel Moderate: frequent 30 Severe: diarrhea, syndrome episodes of bowel or alternating disturbance with diarrhea and abdominal distress constipation, with fairly constant abdominal distress
|
From page 131... ...
Ulcerative colitis Moderate, 30 Moderately severe, 60 Severe: numerous Pronounced: marked with infrequent with frequent attacks a year malnu-trition, anemia, exacerbations exacerbations and malnutrition; and debility, or with health only fair serious complication as during remissions liver abscess Ulcer, duodenal Mild, with 20 Moderate: 40 Moderately 60 Severe: pain only recurring recurring severe: impaired partially relieved symptoms 1-2 episodes of severe health mani- by therapy, times/yr symptoms 2-3 fested by periodic vomit times/yr averaging anemia and ing, recurrent weight loss; hematemesis or ≥10 days; or with continuous or recurrent melena, with moderate incapacitating anemia and weight manifestations loss producing episodes ≥ 10 impaired health days for ≥ 4 times/yr Hiatal hernia Two or more of 30 Recurrent epi- 60 Pain, vomiting, the symptoms gastric distress weight loss and from the 30% with dysphagia, hematemesis evaluation, but of pyrosis, and or melena with less severity regurgitation, moderate anemia; accompanied by or other symptom substernal or arm combinations or shoulder pain; producing severe with con-siderable health impairment health impairment continued
|
From page 132... ...
TABLE 5-2 Continued Condition 10% 20-30% 40-50% 60-70% 100% Inguinal hernia Postoperative 30 Small, post- 60 Large, post recurrent, readily operative operative, reducible, and well recurrent, or recurrent, or supported by truss unoperated inoperable and not or belt irremediable not readily supported well supported or reducible by truss, or not readily reducible Renal dysfunctione 30 Constant or 60 Constant Chronic dialysis; or recurring albuminuria with sedentary because of: albuminuria with some edema; or persistent edema and casts or red blood definite decrease in albuminuria; or BUN cells; or transient/ kidney function; > 80; or creatinine slight edema or or hypertension > 8; or marked organ dysfunction, especially hypertension ≥ ≥ 40% disabling 10% disabling under code 7101 cardiovascular under diagnostic code 7101 Voiding dysfunction 20 Requires wearing 40 Requires 60 Requires use of absorbent wearing of of appliance or materials which absorbent absorbents which must be changed materials must be changed < 2 times/day which must be > 4 times/day changed 2-4 times/day
|
From page 133... ...
Urinary frequency Daytime voiding 20 Daytime voiding 40 Daytime interval 2-3 hr; or interval 1-2 hr; or voiding interval nocturia 2 times nocturia 3-4 times < 1 hr; or per night per night nocturia ≥ 5 times per night Disease, injury or Symptoms that 30 Symptoms not adhesions of female require continuous controlled by reproductive organs treatment continuous treatment Uterus and ovaries, 30 Uterus only or 50 Uterus and both removal both ovaries ovaries Breast surgerye 30 Unilateral 40 Unilateral 60 Bilateral modi breast surgery modified radical fied radical with significant mastectomy mastectomy alterations in size Unilateral radi or focus 50 cal mastectomy; or bilateral breast surgery with significant alterations Anemia 30 70 Hemoglobin ≤10 Hemoglobin ≤ 8 Hemoglobin ≤ 7 Hemoglobin ≤ 5, with with symptoms like with symptoms with dyspnea on high output CHF or weakness, fatigue, like weakness, mild exertion, dyspnea at rest or headaches fatigue, dyspnea, or tachycardia headaches, or (100-120) , or lightheadedness cardiomegaly or syncope (≥ 3 in past 6 months)
|
From page 134... ...
TABLE 5-2 Continued Condition 10% 20-30% 40-50% 60-70% 100% Dermatitis or eczema 5-19% of body; 30 20-40% of body; 60 > 40% of body; or or systemic or systemic constant systemic corticosteroid or corticosteroid or corticosteroid immunosuppressive immunosuppressive or immuno drugs required for drugs required for suppressive drugs < 6 wks in past 12 required in past ≥ 6 wks in past 12 months months 12 months Urticaria 30 Debilitating 60 Debilitating Episodes ≥ 4 times in past 12 months; episodes ≥ 4 episodes ≥ 4 times and responding to times in past 12 in past 12 months, antihistamines or months, requiring despite continuous sympathomimetics intermittent systemic systemic immunosup immunosuppresive presive therapy therapy Acne Deep acne < 40% 30 Deep acne ≥ 40% face/neck or face/neck elsewhere Hypothyroidism Fatigability, 30 Fatigability, 60 Muscular Cold intolerance, or continuous constipation, and weakness, mental muscular weak medication mental sluggishness disturbance, and ness, cardiovascu required for weight gain lar involvement, control mental changes (e.g., dementia, depression) , bradycardia (< 60 beats/min)
|
From page 135... ...
Addison's disease 20 1-2 crises or 2-4 40 60 3 crises or ≥ 5 ≥ 4 crises in past episodes in past episodes in past 12 months 12 months; or 12 months weakness and fatigability; or corticosteroids required for control Diabetes mellitus Manageable by 20 Requiring 40 Requiring 60 Requiring insulin, Requiring > 1 daily restricted diet only insulin or oral insulin, with ketoacidosis injection of insulin, hypoglycemics and restricted diet, or hypoglycemia with ketoacidosis or restricted diet and regulation hypoglycemia requiring requiring ≥ 1-2 of activities hospitalizations ≥ 3 hospitalizations/yr /yr or twice-a- or weekly clinic visits, month clinic visits, plus either progressive plus complications loss of weight/strength that would be not or complications that be compensable if would be compensable separately rated if separately rated Migraine Prostrating attacks 30 Prostrating attacks 50 Very frequent on average of one on average of once completely in 2 months over a month over last prostrating last several months several months and prolonged attacks, with economic inadaptablity continued
|
From page 136... ...
eThere is also an 80 percent disability level for these conditions, defined as follows: • renal dysfunction that is characterized by persistent edema and albuminuria with BUN 40-80; or creatinine 4-8; or poor health with lethargy, anorexia, weight loss, or limitation of exertion (renal dysfunction)
|
From page 137... ...
. According to 38 CFR §4.1, "the percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations." Thus, the overriding consideration in setting the VASRD ratings does not seem to be providing compensation for pain and suffering
|
From page 138... ...
Other features leading to low levels of disability include symptoms being mild and episodic, the disease being minimal according to laboratory parameters, and the ability to control the disease well with simple treatments. Factors that Influence Disability Ratings While the overarching consideration in VASRD ratings is a disorder's effect on earnings capacity, Table 5-5 summarizes a number of secondary factors that also influence percentage ratings.
|
From page 139... ...
Disorder Severity level 9200s–9400s Mental disorders Symptoms neither cause occupational and social impairment nor require continuous medication 6510 Sinusitis Detected by X-ray only 6315 HIV-related illness Asymptomatic, with or without lymphadenopathy or low T4 count 7319 Irritable bowel Mild disturbances of bowel function; occasional syndrome abdominal distress 7338 Hernia, inguinal Not operated but remediable; or small, reducible, no true protrusion 7500s Renal dysfunction Albuminuria and casts with history of acute nephritis 7610–7615 Diseases of female Symptoms that do not require continuous reproductive organs treatment 7619 Ovary Removal of one ovary with or without partial removal of the other 7626 Breast surgery Wide local excision, without significant alteration of size or focus 7700 Anemia Hemoglobin < 10 gm/100 ml, but asymptomatic 7806 Dermatitis or < 5% of body and only topical therapy required eczema during past year 7823 Vitiligo With no exposed areas affected 7828 Acne Only superficial (comedones, papules, pustules) , not deep acne 8100 Migraine Attacks less than once in two months in last several months.
|
From page 140... ...
cases of low back pain, and mental disorders such as depression, anxiety, and PTSD. Table 5-2 offers a number of examples of how disability ratings are assigned for these disorders.
|
From page 141... ...
. This would suggest that objective findings are to be sought by the examiner before using pain alone as a basis for disability.
|
From page 142... ...
that may influence percentage ratings cannot be met for mental disorders. This could theoretically put mental disorders at a relative disadvantage compared to physical disorders in terms of achieving higher percentage ratings.
|
From page 143... ...
6,255 6,299 6,312 6,440 6,501 6,612 6,691 6,783 8.4% 0.2% Irritable bowel 3,406 3,515 3,622 3,787 3,987 4,189 4,359 4,607 35.3% 0.2% syndrome (7319) Major depression 4,570 6,458 8,173 10,609 14,212 17,848 22,024 26,226 473.9% 1.0% (9434)
|
From page 144... ...
* The primary rated service-connected disability is either the condition rated as most disabling or equal to the highest rated condition.
|
From page 145... ...
Trends in Disability Compensation Numbers of Veterans Receiving Disability Compensation In response to a request, VA provided the committee with data regarding the numbers of veterans receiving disability benefits for the years 1999– 2006. Table 5-6 categorizes these data by the primary rated disability that is either the condition rated as most disabling or equal to the highest rated condition.
|
From page 146... ...
1,561 2,059 2,548 3,218 4,070 4,810 5,630 6,351 306.9% 0.2% Colitis (7323) 7,843 7,953 8,031 8,273 8,515 8,746 8,963 9,205 17.4% 0.3% Irritable bowel syndrome (7319)
|
From page 147... ...
Trends in Combined Ratings, Future Exams, and IU Designations Table 5-9 describes changes between 1999 and 2006, by diagnostic category, in the mean combined rating of a disorder, in the percentages of beneficiaries classified as IU, and in the percentage of beneficiaries for whom a future exam is scheduled. The data on combined ratings show that the ratings had a modest upward trend in almost all diagnostic categories 14 Defined as either the condition rated as most disabling or equal to the highest rated condition.
|
From page 148... ...
59.6 52.9 92.8 89.9 Irritable bowel syndrome (7319) 62.7 53.3 84.1 78.3 Major depression (9434)
|
From page 149... ...
46.2 49.6 3.9 2.8 5.6 8.5 Irritable bowel syndrome (7319) 40.3 49.9 6.1 4.7 11.6 15.8 Major depression (9434)
|
From page 150... ...
A second possibility is that it is more difficult to get access to psychiatric care than it is to get access to care for somatic disorders, so those with psychiatric disorders would have a stronger incentive to seek increased access based on an IU classification. A third possible explanation is that the rigidity in the current rating schedule for PTSD, which focuses on occupational impairment, may lead rating technicians to use IU as a means to account for individualized circumstances that can otherwise not be accounted for under the schedule.
|
From page 151... ...
• Data should be gathered and coded at two points in the process where there is currently little information available: before claims are made, and after compensation decisions are rendered. Data such as these will facilitate more informed future analyses of PTSD disability compensation issues.
|
From page 152... ...
. The AMA publication offers guidance on several aspects of assessing mental disorders, including the variability of function over time, information sources, claimant motivation, persistence of functional impairment, the dimensions of a functional assessment, determination of social functioning, and the role of treatment response.
|
From page 153... ...
Advice is provided in §14.3b: Impaired social functioning may be demonstrated by a history of alterca tions, evictions, firings, fear of strangers, avoidance of interpersonal rela tionships, social isolation, or similar events or characteristics. Strength in social functioning may be documented by an individual's ability to initiate social contact with others, communicate clearly with others, and interact and actively participate in group activities.
|
From page 154... ...
. Functional limitations are assessed in four areas: activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation.
|
From page 155... ...
Evidence of impairment of social functioning may include a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation. Conversely, strength in social functioning can be exhibited by participation in group activities, consideration for others, awareness of others' feelings, and the ability to initiate social contacts and communicate clearly with others.
|
From page 156... ...
However, in response to VA's charge, the committee offers for VA's consideration a framework that it developed for establishing a revised PTSD disability rating system. This framework -- illustrated in Table 5-11 -- takes a multidimensional approach in order to provide a more comprehensive evaluation of disability.
|
From page 157... ...
Furthermore, having occupational impairment as one of several dimensions -- rather than as the predominant factor -- in rating disability would result in greater parity between the rating of mental disorders and physical disorders. Treatment factors such as intensity, complexity, and response are given a discrete dimension in the framework, as is the case for a number of physical disorders rated in the VASRD.
|
From page 158... ...
The percentage ratings provided in each row of Table 5-11 should not be taken as a final recommendation but instead are intended to illustrate how such a multidimensional approach is compatible with the current VASRD ordinal rating system. Furthermore, it should be noted that the percentage ratings are not intended to read across a row; in other words, it is not the intent to require an individual to meet a particular severity level in every dimension in order to qualify for that VASRD disability rating -- for example, requiring that an individual be given Level III ratings or greater on all five dimensions in order to attain a 50 percent disability rating.
|
From page 159... ...
highest-rated domains. • Hierarchical domains approach: assign greater weight to certain domains (for example, symptom severity > occupational impairment > psychosocial functioning > treatment response > quality of life)
|
From page 160... ...
aThese percentage ratings are not intended to read across a row, i.e., requiring an individual to meet a particular severity level across all dimensions in order to qualify for that VASRD disability rating (e.g., Level III ratings or greater on all five dimensions to attain a 50 percent disability rating)
|
From page 161... ...
, though the validity and applicability of each approach would need to be determined. Also the fact that medical disorders may be rated 100 percent without requiring total "unemployability" suggests Level V could be coded for profound occupational impairment in a person who is sporadically employed (to avoid disincentives to return to work)
|
From page 162... ...
However, it is up to VA to implement the program in a manner that facilitates open communications between clinicians, remote raters, and other dispersed personnel and ensures that the claimants and those who help them are not disadvantaged. The Institute of Medicine report A st Century System for Evaluating Veterans for Disability Benefits, which will be released in summer 2007, will also address and offer recommendations regarding the C&P examination and disability rating processes.
|
From page 163... ...
2005b. Review of State Variances in VA Disability Compensation Payments.
|
From page 164... ...
2005. Veterans Benefits Administration Manual M-MR, Part III, Chapter , General Claims Process, Subpart IV, General Rating Process.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.