(cell phone 301-651-6392)

To: All veterans

Date: Nov 2014

From:

Topic: Aggravation

Craig N. Bash, M.D.

Veteran Independent Medical Opinion/Exam-

Neuro-Radiologist
www.veteransmedadvisor.com

IMO/IME
Veteran Medical Nexus Opinion (VMNO)
Pages: 2

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 on Aggravation:
Aggravation of medical conditions is a complex concept because the physician needs to know the
natural progression of disease without aggravation. A patients non-aggravated natural progression of
any disease depends on the stresses that the patient would normally place on a disease process and
to some extent the age and genetics of the patient.
A classic example is a patient who injures their lumbar spine in service and has service connection or
pending service connection for their lumbar spine and then they get into an auto accident or have a
major fall. Many times, these patients have worsening symptoms following these major types of
accidents and usually the VAs reflexive response is to say that the out of service accident caused the
patients worsening of symptoms. In order to sort this out the physician needs to carefully review the
pre-accident medical records and determine the worsening glide slope of the patients pre-accident
spine degenerative disease. Often imaging studies are useful here because following most accidents
the patient will have a new set of images done and these can be compared to prior images to assess
worsening. This requires a skilled radiologist for accurate assessments. Once the glide slope is
determined than the physician needs to see if the accident made the condition worse and access if the
patient had not had his/her service injure whether or not the post accident condition would have been
as severe. In other words, if not for the service time injury would this patient now have as severe a
spine injury. If the patient had a pending service condition then the physician must also assess
whether the accident was the sole cause of the patients post accident condition or if the patient had
pre-accident residuals from his service injuries that would be related to service. The above processes
are very complicated.
To further add complexity some patients have several accidents or even have surgeries along their life
course thus each pre and post set of medical records needs to be analyzed as above. This sort of
analysis and report production can take several days to a week assuming the full medical records and
images are available. Often the VA does not have all the outside medical records pre-and post
accident and many VA CP physicians simple do not have the time to do this analysis in the routine CP
exam and thus the patients aggravation would not be fully documented. Of course, a physician with
many years of experience is better able to determine the glide slope of the normal aging process as
younger physicians simply have not seen the natural progression of many diseases because their
experience is often limited to the acute manifestations of disease and not the longitudinal care of

patents from a young age to elderly. Furthermore, each disease process has a difference aging
process.
Pre-existing to service conditions require a similar approach in that all the pre-service medical records
need to be gathered and analyses in relationship to any disease processes that occur in service then
an assessment of abnormal disease progression needs to be made. Again many years experience
with medicine is useful to determine aberrant progression, which would be aggravation. Another key
concept is that most patients enter service fit for duty thus many pre-existing conditions often involve
a patients self description of some process that usually had not been diagnosed prior to service or
was not identified on entry and/or was not treated prior to service by a physician. These conditions
are healed fully prior to entry and do not meet the requirement s of pre-existing conditions. These
processes however can cause a complex VA administrative legal response because the reflexive
response here is for the VA to assign all new conditions that the patient might acquire in service to any
pre-existing historically healed conditions.
.
Prior to the aggravation CP exam best to Do the following;
1. Do get new lay statements for the examiner.
2. Do gather all old pre-service, service and post service medical records and x-rays-imaging
studies-laboratory reports.
3. Do prepare a new longitudinal medical opinion -Veteran Independent Medical Opinion/ExamIMO/IME-Veteran Medical Nexus Opinion (VMNO) prior to the exam to give to the examiner
so that a review of your entry medical records can be done prior to the VA decision.
4. Do ask examiner for a copy of his/her report ASAP after the exam.
Do not:
1. Do not simply accept a non-aggravation decision by the VA as these decisions require a through
analysis by a physician and until you have had this analysis your aggravation conditions may
not be well documented.
Recommendation: Get our own IME/IMO prior to the exam as this is the best way that you can fully
describe your medical condition (plus any aggravated conditions) to the VA examiner because your
doctors IME/IMO should be based on a longitudinal review of your records and will be in medical
language that your VA examiner will understand very clearly.

Craig Bash M.D.

Associate Professor

drbash@doctor.com cell 240-506-1556

Veteran Independent Medical Opinion/Exam- IMO/IME

Veteran Medical Nexus Opinion (VMNO)

based on Veterans medical records