(cell phone 301-651-6392)

To: All veterans

Date: Oct 2014
Topic: Prostate cancer reduction-ratings
Independent Veteran Medical Opinion
(IMO)Veteran Medical Nexus Opinion
(VMNO)
Pages: 2 pages

From:
Craig N. Bash, M.D.
Neuro-Radiologist
www.veteransmedadvisor.com

NPI or UPIN-1225123318- lic #--D43471

4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589
E-Mail: drbash@doctor.com

Update:
Prostate cancer reduction-ratings (medical diagnostic codes) are confusing because often the patient
has a 100% disease cancer code for 6 months then the code is reduced and the reasoning is often
unclear to the patient. The VA goes through a two-step time period process that includes a first 60
days for the proposal to reduce and then another 60 days after the reduction decision is made (whole
process takes 120 or more days). The BVA (Board of Veterans Appeals) has stated the following in
recent decisions concerning the process:
in any rating-reduction case, not only must it be determined that an improvement in a disability
has actually occurred but also that that improvement actually reflects an improvement in the
Veteran's ability to function under the ordinary conditions of life and work. See Faust v. West, 13
Vet. App. 342, 350 (2000).
AND
cessation of surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure, the
rating of 100 percent shall continue with a mandatory VA examination at the expiration of six
months. following the cessation of surgical, X-ray, antineoplastic chemotherapy, or another
therapeutic procedure, if no local recurrence or metastasis

So at the end of 6 months, the VA will re-evaluate the medical diagnostic codes and potentially
propose a 60 day time period of reduction based on an Exam, which will look at the residuals of:
1. local recurrence or metastasis
2. voiding dysfunction= of voiding dysfunction are rated as either urine leakage, frequency, or
obstructed voiding, post-surgical urinary diversion, urinary incontinence, stress incontinence,
appliance or the wearing of absorbent materials
3. renal dysfunction= constant albuminuria, edema; or, definite decrease in kidney function,
hypertension, blood urea nitrogen (BUN), creatinine, generalized poor health-characterized by
lethargy, weakness, anorexia, weight loss, limitation of exertion, dialysis, sedentary activity

During the first 60 day proposal re-evaluation period the VA will often simply look at the patients post
treatment PSA (prostate specific antigen) which is usually low - around the <.1 level- thus the VA will
sometimes incorrectly reduce the code to 10% if the rest of the limited residuals listed above are
normal. Patients may or may not have an enlarged prostate gland following treatments, with a simple
enlarged gland, without biopsy proof of residual or recurrent tumor, the VA will still reduce the code to
10% or even 0%.
It this approach, the VA incorrectly lowers the medical diagnostic code because other secondary
conditions are not evaluated. For example, a large prostate gland could harbor residual cancer
therefore a biopsy might be needed. The basic serum BUN and creatinine levels can under-estimate
the patients residual real renal dysfunction thus a 24-hour urine and creatinine clearance should be
done along with GFR (glomerular filtration rate). Other secondary conditions, such as urine
incontinence should be evaluated with urodynamic studies and bowel incontinence due to surgery,
radiation or chemotherapy should be evaluated with a careful history and defecata-gram if needed.
Secondary chemotherapy effects should be evaluated in organs such as the brain, liver and heart.
Finally, often patients cannot return to work due to secondary conditions (urine/stool leakage and
appliance wear) thus they should be considered for TDIU (total disability individual unemployability or
IU)

Recommendation:
During the 60-120 day re-evaluated period the patient should be fully evaluated for all residuals and
secondary conditions and TDIU by a physician who both understands the complicated VA medical
diagnostic codes and who does additional testing to look for the appropriate secondary conditions.
(n.b. Physician extenders such as nurse practitioners and physician assistants do not routinely have
the depth of knowledge to adequately evaluate all secondary conditions because their advanced
training is limited to the organ system that they work with on a daily basis). During each 60 day step
the patient is able to submit new medical information (Independent Veteran Medical Opinion=IMO
and Veteran Medical Nexus Opinion (VMNO) which is advantageous to the patient as the VA then will
have the most medical information possible to take a fully informed decision- this can even extend the
120 days depending on how the processes the paperwork.
Ideally, in a well-developed post treatment evaluation the patients primary cancer code will decrease
(due to treatment effects) but the patients medical codes for residuals and secondary conditions/TDIU
will increase. In my experience, patients usually will in the final analysis will have a significant post
treatment set of medical diagnostic codes and do not have any reduction in their combined code but
this requires a very pro-active effort on the patients part because all post treatment tests and medical
reports/opinions/evaluations need to submitted to the VA prior to the 60 day window of re-evaluation.
Some patients have requested a re-evaluation hearing and for the hearing opt for an expert medical
witness to be present during the hearing to present the pertinent medical data as these secondary
conditions can be medically intricate.

Craig Bash M.D.

Associate Professor
drbash@doctor.com
cell 240-506-1556

Independent Veteran Medical Opinion (IMO)

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