October 3, 2024 • 61 mins
Bethanie Spangenberg explains the VA's Ear Conditions Disability Benefits Questionnaire (DBQ) and breaks down how veterans can approach ear-related disability claims beyond hearing loss and tinnitus.
• The ear has three parts: external (pinna and ear canal), middle (pressure system with eustachian tube), and internal (balance center)
• Ear conditions DBQ covers inner ear, middle ear, outer ear and infections, but not hearing loss or tinnitus
• Meniere's disease can receive ratings from 30% to 100% depending on frequency and severity of symptoms
• Peripheral vestibular disorders receive 10% for occasional dizziness or 30% with staggering
• External ear infections must show multiple symptoms for a 10% rating
• Mastoiditis (bone infection) is a serious complication requiring prompt treatment
• Physical examination may be limited for inner ear conditions as symptoms aren't always present at exam time
• VA increasingly requires objective test results for compensable inner ear condition ratings
• Look for diagnoses in the "assessment and plan" section of medical records rather than just the formal diagnosis codes
• Consider seeking an Independent Medical Opinion if VA providers aren't documenting conditions properly
For questions about obtaining medical evidence for your VA ear disability claim, contact Valor 4 Vet at 888-448-1011 or visit valor4vet.com
Tune in live every Thursday at 7 PM EST and join the conversation! Click here to listen and chat with us.
Visit J Basser's Exposed Vet Productions (Formerly Exposed Vet Radioshow) YouTube page by clicking here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
J Basser (00:05):
It's time for the Exposed Vet Radio Show.
The Exposed Vet Radio Show, wediscuss issues affecting today's
veteran.
Now here's your host, john andRay.
Welcome, ladies and gentlemen,to another episode of the
Exposed Vet Radio Show.
On this beautiful sunshiny,october 3rd 2024.
(00:28):
Years going by, this is themonth of Halloween, so be
careful with the gooks andgoblins out there, because
they're going to get moreprevalent as the month goes on.
Today we've got Mr Ray Cobb.
He's riding side saddle over onthe side car in the Harley
we're riding.
How are you doing, ray?
Ray Cobb (00:44):
I'm doing great Beautiful day down here today.
That great fall weather startto set in cool in the morning.
We got plenty of rain this lastmonth, so we're liable to have
a gorgeous fall down this way.
J Basser (00:58):
Well, I'm glad I like seeing these things get real
pretty.
Got a treat for you.
Today, folks, we've got ourresident instructor.
I guess her name is BethanySpangenberg.
She is valid for vet, she's theowner of the company and we've
been discussing some stuff hereover the last year or so about
DBQs and different disabilities,and today y'all need to listen
(01:22):
up real close because we'regoing to talk about the ears.
How you doing, bethany?
Bethanie Spangenberg (01:28):
I'm doing well enjoying this beautiful
sunset that we get a little bitearlier, and glad to be on this
side of was it Hurricane Heleneor Helen, what they're saying
Because we had some floodinghere in Southern Ohio and so I'm
glad to be on this side of thestorm Good.
J Basser (01:50):
Well, it was a rough time.
It still is a rough time.
My place is wiped out,especially North Carolina and
eastern Tennessee.
It's bad.
They say I-40 is going to beclosed until September of 2025
between Asheville and Knoxville.
Bethanie Spangenberg (02:07):
Wow, yeah, I saw some videos coming out of
there.
It's terrible.
J Basser (02:13):
Yeah, it is, but I hear today they have no money to
do anything.
I remember feeling they didn'thave any money.
They gave it all away, so Ihope that's not the case.
If it is God, what a mess.
Ray Cobb (02:32):
There's one little community up there in East
Tennessee up close toElizabethan.
They've lost three fire trucks,four police cars and two
ambulances in the flood.
And I know our county.
We gave them two police cars,two patrol cars.
J Basser (02:57):
Okay.
Ray Cobb (02:59):
To try to help, you know, so that they can at least
get around and do some stuff.
J Basser (03:04):
Is the department trying to get it, so they can at
least get around and do somestuff.
Ray Cobb (03:07):
Is that part of the Tri-City?
Well, it would be in theTri-City section yes, kingsport,
johnson City area.
Yep, yep.
J Basser (03:15):
I'm just trying to.
Ray Cobb (03:16):
Elizabeth is about.
Oh, I guess it's only about 20or 25 miles northeast of Johnson
City.
Okay.
J Basser (03:25):
That's close of Johnson City, okay, that's close
to eastern Kentucky.
Okay, well, guys, fair for them.
You send whatever you can.
You know I mean Costco here isalready out of water.
It's been at all down there.
So you know everything isgetting balled up.
But I also got the porch crackgoing on folks, so you think
things can get bad.
We're fixing that empty shelvesagain and things are going to
(03:47):
skyrocket.
So I hope people grow a gardenthis year because they're going
to need the vegetables.
Bethanie Spangenberg (03:54):
Hopefully we get the rain to support the
garden too.
J Basser (03:57):
We need the rain.
We also need to get somebody inthe gubber to put a stop to
that strike and put it back towork.
That's what needs to happen,All right.
Well, let's talk about the ears, Bethany, because we all need
to be able to understand thesituation with the ears.
We've got a couple of betsmissing in.
I know one gentleman.
(04:21):
He hasn't filed a claim yet,but I think he's fixing to.
I think he wants to hear aboutthe ears Well.
Bethanie Spangenberg (04:24):
I appreciate them attending and
hopefully they learned somethingfrom what we talked about today
.
If you are a new listener,we've been covering these DBQs
one by one each month.
I don't think from my standpointthese DBQs are talked about
enough because we want to cover.
Our goal in covering these iskind of talking about each
(04:44):
section and what the veteransshould expect and have prepared
for their condition, talk alittle bit about what each
rating decision means and justkind of have a better
understanding of how thisprocess works from the medical
expert side of things.
So not necessarily the most hottopics or the most
(05:05):
controversial stuff, sohopefully we can keep you a
little bit entertained.
So I'm going to jump into theEar Conditions DBQ.
This DBQ is nine pages long andit has to do with the inner ear
(05:25):
, the middle ear, the outer earand infections.
This is not specific to hearingloss and tinnitus or ringing in
the ears.
Those are separate.
But before we dive into eachsection I do want to talk a
little bit about anatomy andwhat some of these terms mean.
(05:46):
So when we?
talk about the ear and the earstructures, we reference them as
the external ear, the middleear and the internal ear.
So the external ear is the partthat you can touch.
We call that the pinna, andalso includes the ear canal.
(06:07):
That is considered the externalear.
Now, your eardrum, or what wecall the tympanic membrane, the
outer portion, is part of theexternal ear and it creates a
seal from everything else on theinside.
So there is not supposed to beany air or fluid coming from the
(06:32):
inside of the ear to theexternal portion, so that that
eardrum plays a large portion ofour hearing and protecting our
brain from any type of infection.
And protecting our brain fromany type of infection.
Now, the middle ear is thepressure system.
It has to do with theeustachian tube, which is
(06:54):
connecting the inner ear to oursinuses.
So when we change pressures orchange elevation, that
eustachian tube adjusts thepressure in the middle ear so
that way we're not having earpain.
So, for example, if you've everbeen on an airplane, you'll
(07:15):
feel your ears pop.
What you're actually feeling isthat eustachian tube adjusting
to the pressure and theelevation change.
So that's necessary in order toprotect the mechanisms for our
hearing.
Now, the internal ear is yourbalance center and it also helps
(07:37):
you to understand your position.
Now, when I explain how theinner ear kind of functions, or
the internal ear functions, I'mgoing to use a layman example, a
very simplistic example.
So if you're a medicalprofessional listening to me
discuss this, just know that I'mnot using technical terms.
(07:58):
So when you think of how theinner ear functions for balance
and position change, I want youto think about a snow globe and
the confetti or the glitterinside the snow globe.
So our internal ear functionsusing a fluid and crystals
(08:22):
within the fluid.
So if you take a snow globe andyou're not shaking it up right
now, but you're holding the snowglobe and you turn the snow
globe, which shifts the glitterto the bottom because of gravity
.
That is the same process thatoccurs when we change our
position.
So those crystals within ourear adjust to the gravity and
(08:47):
move to give signals about whereour head is positioned in space
.
So if you shake up that snowglobe, that is chaos in your
inner ear and that's where wecan start to get symptoms of
dizziness in your inner ear andthat's where we can start to get
symptoms of dizziness and wecan intentionally like as
(09:09):
children when we're on themerry-go-round, we can
intentionally trigger thedizziness symptoms by spinning
really fast right Makes us dizzy.
But as we get older we could bemore sensitive to that change
and it can create a disease.
And that's where we start toget some of our diseases known
(09:30):
or symptoms such as vertigo, thedizziness that we're not trying
to trigger or we get.
The most common one people talkabout is the benign positional
peripheral vertigo, or BPPV.
That's a big one that peoplelike to claim or even some
symptoms of Meniere's disease,and so we'll break down each
(09:53):
condition as we go through theDBQ.
But I really just wanted to putthat out there and that way
everybody understands thefunction of each section of the
ear.
Does that make sense?
The function?
J Basser (10:09):
of each section of the ear.
Does that make sense?
Bethanie Spangenberg (10:20):
Yes, it does.
Okay, All right.
So as we go on to page one, thesections here on page one are
the standard questions that wesee in every DBQ.
It talks about disclosing therelationship between the
examiner and the veteran, ittalks about what evidence was
reviewed and then it asks aboutthe diagnosis that is to be
addressed.
As always, I highlight thefirst box in the diagnosis
(10:41):
section, and the first box thatthe medical examiner can mark
reads the veteran does not havea current diagnosis associated
with any claimed conditionslisted above.
And this is where I emphasizethat a diagnosis is important to
the clinician in order tounderstand the relationship for
(11:02):
your disability claim.
So, while it may not be legallyrequired, it's a legal argument
If you don't have a diagnosis.
I will say that from themedical expert side of things.
If you have a diagnosis beforeyou go into that compensation
and pension exam, you're savingyourself so much time and so
much energy when it comes toyour disability claim.
(11:25):
It is absolutely recommendedfrom the medical expert
standpoint to go into your compand pen with a diagnosis.
So some of the diagnoses thatare listed on this DBQ are on
the top of page two.
Some of these medical terms mayring a bell to you.
(11:46):
So as I go through there, justknow that these are the
conditions that we're also goingto be discussing briefly today.
So Meniere's syndrome,peripheral vestibular disorder
this is where the vertigo fallsunder.
We have the benign paroxysmalpositional vertigo or the BPPV
that I mentioned.
We have chronic otitis externa,and that is the external ear
(12:13):
infection.
We have chronic superativeotitis media, so media is middle
, and so that is a chronicinfectious disease inside the
middle ear.
We have a chronicnon-superlative otitis media, so
it's more of a, rather than itbeing an infectious fluid.
(12:37):
It's a different type of likeoil almost that's in the middle
ear.
Then we have mastoiditis, whichis an infection of the bone,
and then we have otosclerosis,which is actually arthritis of
the bones inside the ear Part ofhearing.
(12:58):
There is vibration that occursbetween these itty bitty tiny
bones of the ear, vibration thatoccurs between these itty-bitty
tiny bones of the ear and youcan actually develop arthritis
in those itty-bitty bones fromvibration or loud noises and
it's interesting that even thoseteeny bones can develop
(13:19):
arthritis.
But that's what theotosclerosis is okay.
But that's what theotosclerosis is okay.
One other condition that's notlisted on this but is discussed
in the rating schedule istympanic membrane or that
eardrum perforation, and I justwanted to throw that in there
because it does not have arating, a disability rating,
(13:40):
meaning that it's listed withthe diagnostic code but it's at
a 0%.
It's not compensable.
The reason why I bring that upis because the eardrum
perforation can actually becommon for veterans, whether it
comes from an ear infection orsinus issues.
Even trauma can cause aneardrum rupture or perforation
(14:04):
and I just want to mention thatit is not compensable.
But you can get itservice-connected and then file
conditions that may havedeveloped secondary to that
eardrum perforation.
So I think that's important tobriefly mention on there as we
move into Section 2 of thesecond page.
This is the medical history.
(14:24):
We've talked about this withevery DBQ.
That is where the examiner canreview your statement or they
can ask you interview questionsto plug that information inside
the medical history.
Page three, the top of pagethree, talks about medications
that you may be taking for yourear condition, and then section
(14:48):
three is where we really startdiving into what rating
percentages apply to these earconditions.
Do you guys have any questionsso far about what we've talked
about or what I've brought upfor the DBQ?
J Basser (15:10):
That was just thinking .
Yep, three phases, you've gotthe outer ear, the middle ear
and the inner ear.
Is that the face of what you'resaying?
Ray Cobb (15:21):
Yes, that's what I'm saying.
J Basser (15:22):
Okay, so which one is the station, tube dysfunction
being the middle ear?
Bethanie Spangenberg (15:28):
That's going to be the middle ear.
J Basser (15:29):
Okay, that's what I was like.
Okay, it's time to wrap myburner in this, because I've
been fighting this stuff foryears.
Ray Cobb (15:37):
Okay, question real quick, bethany when they say you
have an ear infection, is thatmost of the time on the outer
ear?
Bethanie Spangenberg (15:50):
No, so when somebody says that's going
to be the middle ear.
So what normally happens is themost common term, like when you
hear young children have adouble ear infection.
Most commonly what that is isthey've looked inside the ear
canal and they can see fluid andirritation of that eardrum.
Now, because that eardrumcreates a separation between the
(16:12):
outside world and the insidesinus cavity, the fluid is
actually and the infection isactually inside of that metal
ear.
The interesting part is thatthe eustachian tube, which
controls the pressure and issupposed to allow air in and out
of that middle ear, what canhappen is bacteria from the
(16:35):
sinuses can go up into thateustachian tube and irritate
what's inside the middle ear.
So most often when we havethese middle ear infections or
young children have earinfections, it's not necessarily
that the ear is not functioningcorrectly.
It's that eustachian tubethat's not functioning correctly
(16:57):
and that's coming from sinusirritation.
So sinusitis, allergies, coldviruses.
(17:18):
So sinusitis, allergies, coldviruses those things are what
contributes to dysfunction ofthat eustachian tube and then
prompts bacteria into the middleear and causes those ear
infections.
J Basser (17:29):
So that's a good question because now we're
connecting dots of rhinitis,sinusitis, ear infection, that
kind of thing.
So that's a good question, butthat usually requires tubes to
be placed in right.
It usually requires what Tubes,tubes?
Bethanie Spangenberg (17:49):
Ear tubes, yeah, tubes, yeah.
So ear tubes can becontroversial, especially in
your younger children, becausesometimes they're really.
Some clinicians believe thatthey're not treating the
underlying issue.
They're not treating theallergies or the sinus issues,
or whether it's environmentalallergies or symptomatic
treatment of viruses, so they'renot getting control of that
(18:09):
inflammation within the sinuscavity which is causing that
tube to malfunction.
So, some clinicians believe thatear tubes are a band-aid on the
problem and they're not trulyaddressing the issue, and ear
tubes can then go on and causescarring, which causes hearing
loss and issues within you knowas they age.
(18:32):
Some clinicians believe thatthey should be treating the
underlying issue rather thanjumping to ear tubes.
I don't know that's a topic.
That's a whole other show, Ithink in and of itself.
But as adults, I have seenadults get ear tubes because
they can't get control of thesinus issue and it leads to
(18:53):
frequent ear infection.
Ear tubes as adults aredifficult because you don't have
the healing and recovery thatyou have in your childhood.
So ear tubes as adults you'rereally taking a risk of hearing
loss because you don't have thehealing and recovery that you
have in your childhood.
So ear tubes as adults you'rereally taking a risk of hearing
loss that may develop followingthe ear tube placement.
That's a discussion betweeneach clinician and each patient
(19:18):
with their provider.
J Basser (19:20):
How about 17 over 20 years?
Bethanie Spangenberg (19:24):
That can cause some hearing loss.
J Basser (19:26):
What did you say?
Bethanie Spangenberg (19:28):
Exactly so .
While we're on the topic of theear infection, like when
somebody goes in and says an earinfection, the only way that
you're really going to get anexternal ear infection is from
something irritating the skinsurface, Because the eardrum
(19:51):
does create a barrier betweenthe outside world and the inside
of the sinus cavity.
Then anything that is on theoutside of the eardrum that gets
infected is either coming fromtrauma of the skin, like people
putting paper clips in their earto get something out of their
(20:11):
ear, or somebody taking theirfingernail and scratching their
ear by accident, like somethingitched and then they scratched
their ear.
So whenever we talk aboutinfections of the external ear,
it's most commonly going to becoming from some type of trauma
to the skin surface itself.
Okay.
(20:33):
So when we jump to page three,section three, this is where a
lot of the ratings are Like.
This is the dense area of whereour rating percentages come
from for vestibular conditions,and when we talk about
vestibular conditions, we'retalking about conditions of the
internal ear that affects ourbalance and our position.
(20:55):
So when I talk about, or Imentioned the peripheral
vestibular disorder, okay, theperipheral vestibular disorder,
okay, that's what they arereferencing in Diagnostic Code
6204, but that's also commonlyvertigo okay.
(21:18):
This is also the benign,paroxysmal positional vertigo
which we get.
A lot of veterans that havethat diagnosis and they claim
that secondary to a conditionthat also falls under diagnostic
code 6204.
Now, clinically, meniere'ssyndrome is also a peripheral
(21:39):
vestibular disorder that affectsthe internal ear, but it gets
its own rating schedule and itsown diagnostic code under 6205.
And so as I go through Section3, I'm going to kind of talk
about what each percentage meansfor these conditions.
(21:59):
Okay, so Section 3 asksspecifically about hearing
impairment with vertigo andthey're asking that because of
Meniere's disease.
Now I guess I should explainthat Meniere's disease does
affect the internal ear but italso creates symptoms of hearing
(22:24):
loss and ringing of the earsand Meniere's disease when a
veteran gets diagnosed with itit's something that they have
been dealing with for a while.
That usually takes severaldoctor's visits in order to
capture that diagnosis.
Often we see patients will comein and they will talk about
(22:46):
having some hearing issues andprimarily the vertigo complaints
, the dizzy that you know.
They feel like the room isspinning and they may develop
some nausea with that dizziness,and so when they come in, the
primary care doctor or themid-level practitioner may try
(23:08):
to do a physical examination,they may try to do some what we
call maneuvers in order tonarrow down what may be
occurring, be occurring.
So there's some clinical toolswe can use as far as like
(23:28):
position change to trigger thesymptoms, or head movements to
trigger the symptoms, and ifthose become positive, then we
can say, okay, well, we aresuspecting that it may be this
condition, and then we give amedication or we throw a
medication out and we say okaywe're going to try this
medication.
If it helps, great.
We'll have you follow up in acouple of months to see if
anything changes.
So if the veteran or thepatient says, well, it went away
(23:53):
with that medication, sometimesthey don't come back, and then
a few months down the line theymay develop another episode, and
so it can typically take awhile before a veteran or a
patient narrows down thediagnosis of Meniere's disease.
What happens is those episodesbecome more frequent, or they're
(24:14):
not helped with medication, orthey're persistent, and so it
can take a while for a veteranto actually capture the
diagnosis of Meniere's.
They are often referred to aspecialist, either an ears, nose
and throat specialist or a teamof an ENT specialist and an
(24:35):
audiologist, before they trulyget the workup that is necessary
to diagnose them with Meniere'sdisease.
With Meniere's, if you havehearing impairment and a vertigo
less than once a month, you geta 30% rating.
The next symptom for Meniere'srating is hearing impairment,
(24:59):
with attacks of vertigo anddifficulties with gait or
unsteadiness.
If you get that one to fourtimes per month, it's a 60%
rating for Meniere's.
If you get it more than onceweekly, it is a 100% rating for
Meniere's.
At Valor for Vet.
That is a big one that veteransare trying to service connect
(25:21):
once they capture the diagnosisof Meniere's because of that
high rating and it can bepersistent and overwhelming and
cause the nausea and vomitingand discomfort with the disease
because of the symptoms.
So, continuing with Section 3of the symptoms, tinnitus is
(25:42):
mentioned on there.
That's really just to promptthe additional DBQ.
Hearing loss is also on thesymptom questionnaire and that's
again to prompt the other DBQfor the audiologist to conduct
for hearing loss and tinnitus.
(26:03):
And then the other question onthe symptom section for section
three is vertigo, which we'vetalked about significantly, and
if you have vertigo it is a 10%rating.
Or you have vertigo with thestaggering symptoms or the gait
(26:26):
unsteadiness, the staggeringsymptoms or the gait
unsteadiness, those together area 30% rating for vertigo or the
vestibular inner ear disorders.
So if you have a vestibular orinner ear condition, often the
symptoms are the dizziness andsome unsteadiness on your feet
(26:47):
because of the dizziness.
So that's a 30% rating forthose conditions.
So there could be a little bitof meat on the bones, I guess,
for those conditions if you getthem service connected.
Any questions about the innerear?
J Basser (27:09):
As far as unsteadiness , I mean, if you've got that
condition, you're in steadywalking, you're going to need
help transferring and thingslike that where a person falls
off or a dependent is based onsomething like that.
They can.
Bethanie Spangenberg (27:21):
They can, depending on the frequency of
the symptoms.
If it's something that occursonce or twice a year, maybe not,
but if it's something that ispersistent and you require the
assistance of another because ofit, then absolutely.
Now, if we move on to Section 4, this is to do with the ear
(27:44):
infections of the external ear,with the ear infections of the
external ear.
Okay.
So section four.
It covers infections andinflammatory ear conditions.
But primarily the ratingschedule for this section is for
that chronic external earinfection.
Okay.
Now for you to get a 10% ratingfor an external ear infection
(28:31):
that is chronic, you have tohave swelling, dry and scaly
skin, drainage from the earcanal, itching and requires
frequent and prolonged treatment.
I don't know that I've everseen an external otitis ear
infection have all of those andthat is a 10% rating.
So that's not a for me.
It's not a realistic thing tosee in the clinic or for a
disability rating thing to seein the clinic or for a
(28:53):
disability rating.
Section four continues to askquestions about
infection-related conditions andthat's to prompt another DBQ,
for example, bone loss of theskull.
You can get a disability ratingif the ear infection goes into
the bone behind the ear.
That is what we callmastoiditis and sometimes with
(29:15):
mastoiditis they have to go inand remove that section of bone
because there is chronicinfection in there.
I have seen that a few timeswith patients who have.
Normally it's not likesomething that occurs because of
chronic otitis media, but it'ssomething that occurs as like a
(29:36):
random fluke.
They get a really severe earinfection one time and it just
decides to seed into the bonethat's close to that ear
infection and then they go inand they have to have part of it
removed.
Once you have mastoiditis orinfection in that bone area,
it's actually a pretty seriouscondition because it is so close
(29:56):
to the brain.
You start to worry about theinfection causing issues with
the area around the brain oreven getting into growing to
cause pressure in parts of thebrain.
So once you get mastoiditis orinfection into the bone, it's a
pretty significant conditionwhere the individual has
(30:17):
experienced, you know, somechronic issues to lead up to
that.
So that actually covers Section4 for infection.
Do you guys have any questionsabout that?
Ray Cobb (30:32):
No, is it hard to get those infections cleared up?
Bethanie Spangenberg (30:37):
If you don't treat the underlying issue
absolutely with mastoiditiswhen it gets into the bone.
If you catch it early enough,iv therapy can usually help.
You always have to watch forrecurrence in case the
antibiotics didn't get all ofthe bacteria.
(30:58):
But once it's into the bone andit's not responding, it can be
I mean, that's where they gointo removing the bone itself
because they're having so muchissue.
To control it.
It can be difficult at thatpoint.
So moving on to Section 5, onpage 4, section 5 talks about
(31:22):
surgical treatment.
This is just a genericfill-in-the-blank.
What kind of surgery?
When did it happen?
Was it left or right side?
What was it for?
And then I ask about anyresiduals related to surgery.
And then we jump to page five.
Page five and six are bothdedicated to the physical
(31:44):
examination, to the physicalexamination.
Now I will say that for most ofthe ear conditions that are
covered for the CBQ a physicalexamination is not required.
So if I look at the veteran'sfile and I see that he has a
diagnosis of Meniere's, thelikelihood of me seeing anything
(32:08):
related to that Meniere's bydoing a physical exam is low,
especially if they're not havingactive symptoms for that day.
So because Meniere's affectsthe inner ear.
I cannot see the inner ear bydoing a physical examination.
The only way that we can reallyassess the inner ear is by
(32:30):
doing images and doing maneuversor tests in order to capture or
trigger those symptoms.
So whenever a veteran goes infor their compensation and
pension examination they may nothave a physical exam at all for
the ear conditions that they'reclaiming.
(32:51):
So, for example, the first partto examine is the external ear.
The external ear as it relatesto Meniere's has no value for me
to look at it, so they may notdo the exam.
Has no value for me to look atit, so they may not do the exam.
(33:12):
The next section is for the earcanal.
Again, for some of those innerear conditions the canal does
not play a role in that diseaseprocess, so they may not look
into it.
And then we have the tympanicmembrane or the eardrum that the
examiner is to look at.
And there is an option here forthe examiner to say let me read
it word for word to you.
It says let me see, oh, exam oftympanic membrane is not
(33:42):
indicated, or exam of the earcanal is not indicated.
So they have the option ofmarking that on the DBQ and
moving on On page six, this isthose specific maneuvers that I
was talking about, that aretools used to help us suspect a
diagnosis.
(34:10):
So normally if a patient comesinto the clinic and complains of
dizziness and I'm suspectingsome type of inner ear complaint
, I will watch them walk, butthey may not have an abnormal
walk.
Sometimes they may have somestaggering that we talked about,
but that's not always presentfor a compensation and pension
(34:33):
exam or a visit into the clinic.
Normally that's something thatthey say hey, I'm having trouble
walking, I kind of fell intothe wall at home or at work.
That's normally what we arehearing in the clinic, not
something that we see firsthand.
There's a test called theRomberg test which has to do
(34:54):
with the arm change during anexam.
Basically the individual closestheir eyes, they stick their
arms out inside of them withtheir palms up and they just
hold them there and sometimes wecan see an arm start to drift.
That is more used in the clinicfor a neurologic condition than
(35:16):
it really is for an inner earcondition.
But it's on the DBQ and it's atool that can be used to kind of
support a diagnosis that may befound related to an inner ear
condition.
The next one is a Dix-Hallpiketest and I'm not really going to
explain that because it can bedifficult, but it's a position
(35:39):
change trying to trigger some ofthat dizziness that the patient
may be experiencing that thepatient may be experiencing.
And then there's a limbcoordination test where the
patient can take their indexfinger and they touch the
examiner's finger and then touchtheir nose and the examiner
moves their finger and thatpatient has to touch the tip of
(36:01):
that finger and their nose again.
So some of these things youguys have made down in the
clinic, these are just tools tohelp us kind of narrow down the
diagnosis For compensation ofpension purpose.
They have no value but they aredocumented on the physical exam
.
So I think that's really tomake the clinician feel better
about discussing an inner ear orear condition rather than
(36:25):
coming in and asking aboutsymptoms and then walking away.
I really do, because it has novalue when it comes to a rating
decision.
Any questions about the physicalexam?
Ray Cobb (36:38):
No.
J Basser (36:41):
I've been through quite a few of them and you're
right exactly what that is, yeahright, exactly what it is.
Bethanie Spangenberg (36:47):
Yeah, it's actually if um even like with
someone that you're concernedwith, um like their brain
function, if you're concernedwith a stroke or some type of
dementia or alzheimer's, or evenlike a tumor, the testing that
is done, some of the arm drift,or that Romberg test, the finger
(37:11):
to nose those are prettystandard things, even with the
TBI.
If you have a concussion orwe're in a motor vehicle
accident, the examiner may dosome of these similar
examinations in the clinic toassess how the brain is working.
And again, the inner ear is soclose to the brain that we
(37:33):
really have to use these astools to support our clinical
decision-making.
So if we move on to the DBQ,we're looking at page 7.
We're looking at section 7.
It has to do with tumors andneoplasms.
Since we've covered these DBQs,I really haven't laid heavy on
the tumors and the neoplasms,mainly because the thought
(37:56):
process for each area is aboutthe same.
So it has to do with whetherit's malignant or benign and
what kind of disruption thattumor or growth has created on
the body.
There's nothing specific in therating schedule for tumors and
what we call neoplasms or growthas it relates to the ear
(38:20):
specifically, and if it was, Iwould break it down, but there's
nothing specific to the earconditions as it relates to any
type of tumor or growth.
Moving on to Section 8, we'reactually on the home stretch
when it comes to the DBQ.
Section 8 is the blanket areafor the clinician to discuss any
(38:41):
other physical findings orcomplications that they want to
discuss that they found duringtheir time with the veteran.
Also, the space there or thequestionnaire regarding scars,
which we have discussedpreviously.
Section 9 on page 8.
This is important.
(39:01):
This is the diagnostic testingthat has been done.
There is a section in the CFRthat talks about requiring
objective tests in order to givea compensable rating for any
type of inner ear disease.
So if a veteran is claimingvertigo or the BPPV or MeniereS,
(39:28):
they are going to have toprovide the workup and the test
that show the objective datathat they have that condition.
So that's important.
And, rounding out the DBQ, onpage 9, we're looking at other
testing that may have been donefor the veteran's condition.
(39:52):
Section 10 is that functionalimpact.
As always, I emphasize that youput any type of functional
impact, any type of symptom thatprevents you from doing your
regular function at work or athome is important to document.
(40:14):
As John previously asked aboutaid and attendance, you want to
talk about those limitationsthat you have with the condition
in your statement.
The clinician may not alwaysask about what your functional
impairment is.
They may look at it and say,okay, well, the veteran has told
me about all these symptoms.
(40:34):
That's not going to keep himfrom working, that's not going
to keep her from working, sothey may mark no, that you don't
have any functional impairmentand move on.
So as always, I emphasize, youneed to put that information
into a statement and supportiveclaim to go with your disability
claim.
The last two sections we haveSection 11, which is remarks and
(40:58):
open space for the clinician tomake any comments, and then the
last section, section 12, isthe examiner's certification and
their signature asking aboutyou know their certification,
their license number, thingslike that.
Any questions about the EAR DBQ?
J Basser (41:21):
You heard your Latin clear.
Bethanie Spangenberg (41:27):
I would say that this DBQ is pretty
straightforward.
If the veteran goes in to talkwith the clinician in person,
they can be in and out the doorin 30 minutes with this
examination it would take theclinician maybe 45 minutes to an
hour to do the DBQ and answerany type of medical opinion that
(41:49):
would go with this exam request.
J Basser (41:55):
Well, you know, the most common I guess like the
most common disability withinthe VA system, is public
analysis right.
Bethanie Spangenberg (42:02):
Yes, absolutely Okay.
So, Absolutely Okay, you know,I'm waiting for them to.
J Basser (42:14):
I wonder if they will ever change that?
Bethanie Spangenberg (42:15):
Because they have recently.
If you look at the changes thatthe VA is trying to make as it
relates to disability anddisability ratings, is they're
really trying to put objectivematerial into these conditions
and objective informationbecause they don't want to
believe the veteran and theyfeel like a lot of the
conditions the veteran may beexaggerating.
So if you look at the changesthat they're making, that we've
(42:37):
even talked about, is they'retrying to objectify everything
and they're trying to requirethat there are tests done or
things to prove that they aresuffering from these conditions.
So tinnitus, that is onecondition that is so common,
especially in our militarypopulation, but there is no
(43:00):
objective testing to prove thatthey have this condition.
So I'm interested if they evertouch it?
And if they do, what are theygoing to do?
J Basser (43:13):
I mean I can hear it.
I may not be able to hear it,but I can hear it.
And you know it's prettyterrifying.
I mean I've seen it drivepeople to suicide.
Ray Cobb (43:23):
Yes.
J Basser (43:25):
So pretty bad stuff yes.
Bethanie Spangenberg (43:28):
It's actually interesting to see
because tinnitus is one of thosethings that can affect how a
person communicates and it cancreate a barrier between you
know the veteran that has thecondition and how they interact
in day-to-day life and how theyinteract in day-to-day life.
So I've said this before and Isay this a lot to the people
(43:49):
that I communicate with, is thatif I didn't see it firsthand, I
wouldn't believe it, and so alot of the things that I watch
my veterans suffer with I trulybelieve.
That's why I do what I do isbecause as a young family, I
don't feel like my husbandshould be suffering through some
of the things that he'ssuffering with, and tinnitus and
(44:23):
hearing loss is one of thosethings that you don't.
I guess for myself I wouldn'thave expected to deal with at
this age, because we go to thesoccer game my son's soccer game
and he hears the crowd aroundhim and he doesn't realize that
he's as loud as he is and hewill make comments and then my
elbow goes into his side because, hey, you don't realize how
(44:43):
loud you're saying thesecomments.
You can't say those comments Iget that a lot.
J Basser (44:49):
He gets those comments .
Bethanie Spangenberg (44:49):
I get that a lot.
J Basser (44:50):
It's the elbow, I get that a lot.
I mean, yeah, you don't knowhow loud you are.
You know because you don't knowit.
You know, and it's like mywife's father is, uh, almost
completely deaf.
He's a coal miner and, uh, he'shad hearing aids and all this
stuff for years, butoccasionally he can hear.
Okay, we were trying to get himheadphones and watch TV and
(45:11):
things like that.
But he talks, just like youknow, he's really loud.
Pretty sad, but she looks at melike yes, yes, every time I say
something Shut up, shut up.
Bethanie Spangenberg (45:26):
It's interesting too, because our
children don't appreciate whatis normal as far as a volume to
talk, and so our children, Ieven have to remind our children
like hey, don't talk so loud.
So then I have my son, whodoesn't talk loud at all because
I keep telling everybody tostop talking so loud.
And then you have my olderdaughter who talks really loud.
(45:47):
I'm like, hey, you're too loud.
And so there is nounderstanding in our household
of what is socially acceptablevolume in each you know social
setting, and so it's kind offunny.
J Basser (46:03):
You know how it all, you know you got me thinking
what is the VA going to do withthese conditions?
That there's no test todetermine what it is.
Cannabis is one, but you knowthe biggest one is mental health
.
There's no physical test formental health.
You know Well from what I'veseen so far.
Bethanie Spangenberg (46:22):
what I've seen so far is they're not doing
a good job and I have, you know, made it a point to be more
proactive and watching whenthese conditions open for
comment.
I really feel like you know,being in this role or this very
small area of expertise, is thatI really need to use my voice
(46:44):
to talk about some of what isclinically appropriate and their
goal of requiring objectivefindings.
We talked about the GERD changesand I don't agree with what
they've done on the GERD changes, because there is other ways to
prove objectively that anindividual suffers from these
(47:07):
conditions.
And to require a medicalcondition to be so severe that
it creates complications thatare life-threatening
complications before youcompensate an individual, I
think that's, I don't thinkthat's fair, I don't think
that's right, I don't thinkthat's realistic and you know
(47:30):
idealistic, I guess.
How it affects the workforce ortheir occupational duties or
(47:54):
their functional capacity, Well,GERD creates occupational
impairments and there's the dataand the studies out there and
they don't use those as areference.
They want to use literature thatis 20 years old and say well,
this is how we're justifying itliterature that is 20 years old
and say well, this is how we'rejustifying it so yeah, and so I
(48:16):
feel like I need to be moreproactive in addressing some of
their proposed changes.
J Basser (48:20):
Question on the group last week.
Question on the group.
Last week I was reading thatsomeone said that a lot of VA
providers know a veteran's got acondition and they're recording
in their record but they willnot actually make an official
diagnosis of that condition.
Do you know what makes themreluctant to do that?
Are they afraid the vet's goingto go out and file a claim for
it, or what?
I see that a lot.
Bethanie Spangenberg (48:46):
I can see it being that way.
They're worried about gettingtied up into the whole
disability process.
And so, you know some of theclinicians at the VA, they kind
of get burnout on veteranspushing the latest and hottest
issue.
Veterans pushing the latest andhottest issue.
(49:07):
You know, there's been times inthe past where I've always, you
know, encouraged thoseproviders to just keep their
head down and stay out of themess, Just document the
discussion that you've had anddon't get tied up into what they
are trying to do.
You have to make what isclinically appropriate for your
patient and not what a veteranmay be pushing to do.
(49:31):
And I think we talked aboutthis briefly, about how the GERD
changes are now going to pushthese veterans to want to see
the GI specialist.
Ray Cobb (49:43):
And.
Bethanie Spangenberg (49:43):
I don't necessarily disagree with that
as long as it's clinicallyappropriate.
And I don't necessarilydisagree with that as long as
it's clinically appropriate.
And so that's again.
I tell the clinician.
I know that it's stressful, Iknow it creates a lot of extra
appointments in your workday,but keep your head down, stay
out of the legal mess, documentthe discussion as you would any
(50:05):
other time, and do what'sclinically appropriate.
You cannot allow the disabilityrating schedule and the
political changes to impact yourclinical decision-making.
And it's hard to do, it can beoverwhelming at times, bethany
one thing I've noticed where Igo.
Ray Cobb (50:27):
here the doctors are actually doing they're saying
what needs to be said, butthey're not putting down the
diagnosis itself In the littlesquare where it says your
diagnosis.
They leave that blank.
Now, up above that, they'retelling you know all the
conditions, all the things thatare going on, and then don't do
(50:49):
that.
And then when the guy goes andfiles his claim, they come back
and say well, you didn't have adiagnosis for it, so there's a
couple things that I've seenwith that.
Bethanie Spangenberg (51:02):
So for us in the clinic and how it relates
to disability, it can be not onthe same page.
They're not always on the samepage.
So for me, like in the clinicwhen I would do my charts or
when I do my charts, there's somuch you have to have for
(51:25):
billing purposes.
There's so much you have tohave for billing purposes.
(51:51):
And that's really where adiagnosis code, the diagnosis
portion, so when it comes to aveteran having a diagnosis, it
doesn't require that it is in abilling code, it requires that
it's under the clinician'streatment plan.
So there's a section underassessment and plan in the note
(52:16):
that the clinician will lineitem the diagnosis and maybe
after that diagnosis they willsay their treatment plan.
And so it can be difficult tokind of argue that between the
clinician side and the legalside because they're not putting
it in the diagnosis section fordisability purposes.
(52:42):
Are you following?
what I'm saying yeah exactly Allright the difference is that
basically the note is a freetext versus the billing is a
formal code.
So sometimes the clinician willput what is required for billing
purpose and a formal code, butthey will free text all the
(53:06):
other diagnoses in the note.
So, for example, I would see apatient who would have 23
diagnoses.
I never put all 23 diagnosesinto my insurance bill because
the top three are the only onesthat mattered.
So I would click or insert twoor three codes that would
(53:28):
capture the billing for theinsurance and then the other 19
diagnosis would be in my freetext section of my note and so
they don't correspond.
And when you go to get yourblue button records, the only
ones that fall under thediagnosis section is what the
clinician has put in for billingpurposes.
(53:49):
Now if you're talking about theclinician having a series of
symptoms that's consistent withthe diagnosis, you know, I would
not want to believe that theclinician is trying to gatekeep
that veteran from getting whatis entitled to him.
I wouldn't believe that's so.
That I would believe is eitherclinician inexperience or
(54:10):
they're requiring another visitto confirm the diagnosis.
J Basser (54:14):
Okay, Beth, you just learned something very important
right there.
Anytime you're looking at yournotes and you're trying to see
what's what, pay very specialattention.
It doesn't matter what iswritten in the upper part of the
document.
Go down toward the bottom andyou'll see bottom and you'll see
the assessment and you'll seethe treatment plan.
That is the bread and butter.
Bethanie Spangenberg (54:33):
Yes.
J Basser (54:33):
According to yes.
So you know that's somethingyou guys.
It makes it easier to look atthings when you guys so Well
we'll get, if you're looking forsomething you'll find it.
Go ahead, betsy.
Bethanie Spangenberg (54:49):
We'll get veterans that try to give us the
discharge instructions as proofof treatment for a condition
and we can't accept those asproof because it doesn't open or
allow for us to see what theclinical thought process was and
what the assessment and plan is.
And so when somebody gives usthose discharge instructions
it's like okay, this is patientverbiage.
So when somebody gives us thosedischarge instructions, it's
(55:10):
like okay, this is patientverbiage.
These discharge instructionsare specifically targeted to a
10th grade level for thatpatient to understand what their
diagnosis is and what they needto do to treat it.
It has from a compensation andpension and medical expert side
it has little to no value for usto understand what happened at
(55:30):
that clinical visit.
So we need to see thattreatment record and what that
clinician has put into theirassessment and plan of the
clinical record.
So it has value not only forthe claim and for the veteran to
look at but also for themedical experts.
So you really need to get thoseif you're wanting, you know, to
capture a private opinion.
J Basser (55:54):
And, if need be, guys, you've got a situation like
that and you don't think youhave a diagnosis, you can look
at it.
It's always good to have asecondary backup plan just in
case, and there's a companycalled Vow valid for vets.
You can call up and send theinformation to them and join
their portal with let's just lethim look at your paperwork, see
(56:15):
if you can't work out anindependent medical opinion with
her and her her team, becausethey're good at what they do
well, thank you for the plug,and we're actually going into
our 10th year and we're lookingto celebrate 10 years in the
year of 2025 that we've beendoing what we do and from the
(56:36):
team approach that sets us apartfrom everybody else.
That's what it takes.
It takes a team to build it.
It takes a team to build it.
It takes a team to keep itgoing too.
That's a lot of work, so that'sgood.
I want you to give everybodyyour contact information,
bethany, so in case anybody'slistening out there and wants to
(56:59):
contact you and maybe reach outand touch you and get an IMO,
what's the best way to get ahold of you and the website, and
I'm both.
Tell me the best way to get ahold of you and the website.
Bethanie Spangenberg (57:09):
So our website is Valor V-A-L-O-R.
The number four vet V-E-T dotcom.
You can plug it into Googleclose as you want, and our
website will pop up, or you canplug it into the URL directly.
There's a lot of informationand tools there that you can use
(57:30):
and view to see how we may beable to help you.
It has a process there for youto understand how we work, and
then you can always call us888-448-1011, if you just have
questions and want to talk tosomebody.
We have veterans on our teamthat have been with us for a
while that can help youunderstand how we function and
(57:51):
how we may be able to help you.
J Basser (58:00):
Well, that's a good one.
That's pretty good.
Reach out and touch them folks.
If you need help, they're thereto help.
So it's, uh, you know it's agood thing.
Plus, their rates are really,uh, really really competitive.
They're not very expensive asfar as doing things like that.
They're, uh, you know, good.
Imo is worth the weight in gold, you know, because a lot of
(58:23):
these examiners don't want togive you a diagnosis.
Of course they do have thediagnosis, but it's hard to get
it out of them.
It's kind of like squeezingblood out of a tomato.
But other than that, we've gotabout a minute left.
Bethy, I want to thank you forcoming on again, as usual.
And we'll get together nextmonth and we'll have another
(58:44):
subject to talk about.
I don't know what it is yet,but I'm sure you'll think of
something good.
Bethanie Spangenberg (58:51):
Well, I actually have it in mind.
I think we need to keep goingwith the ear conditions or the
upper respiratory, I guess, ears, nose and throat Transition
into sinusitis and rhinitis,which is a good one, okay, well,
we'll stay with the anatomy ofthat situation and go that way.
J Basser (59:11):
Well, thank you for coming on, buddy, and I
appreciate your help, man.
Ray Cobb (59:14):
Yeah, no problem, glad to be here and Bethany thanks
Every time she's on.
I learn a little something elseabout my own medical stuff, you
know, and so it's a big help.
J Basser (59:25):
I put that on there every time she's in.
I said join us, as I learnsomething every time Bethany
appears on the show.
Ray Cobb (59:31):
Yeah.
J Basser (59:31):
Well, listen.
That'll be it for today.
This is John, on behalf of Rayand Bethany, and the Exposed
that Radio Show will be signingoff for now.
You have been listening to theExposed that Podcast.
Any opinions expressed on theshow are the opinions of the
guest speakers and notnecessarily the opinions of
Expose that, exposethatcom orBlogTalkRadio.
(59:53):
Tune in next week for anotherepisode of the Expose that
podcast.
Thanks for listening.
Ad (01:00:05):
You have to celebrate your wins.
We've won the Mint 400, andI've celebrated that win for
weeks.
But then we had to focus andmove on.
Dustin Jones,championship-winning Can-Am
off-road racer.
Can-am's the same the most racewins in all types of terrain
with the Maverick X3.
But then they focus and move onthe Maverick R 240 horsepower
in the first, seven-speeddual-clutch transmission.
(01:00:27):
This thing's a game-changer.
We celebrate those wins, butnever for too long.
The Can-Am Maverick X3 andMaverick R Visit CanAmOffroadcom
.
In the world of architecture,engineering and construction,
every detail counts.
That's why over 3 millionprofessionals trust Bluebeam for
PDF markups, digital workflowsand project collaboration.
Whether you're an architect,engineer or project manager,
(01:00:51):
bluebeam's easy-to-use softwarehelps you communicate clearly,
collaborate in real time and getmore done faster.
And the best part, you can tryBluebeam for free for 14 days,
no credit card required.
Visit bluebeamcom today.
It's time for the Exposed Vet Radio Show.
The Exposed Vet Radio Show, wediscuss issues affecting today's
veteran.
Now here's your host, john andRay.
Welcome, ladies and gentlemen,to another episode of the
Exposed Vet Radio Show.
On this beautiful sunshiny,october 3rd 2024.
(00:28):
Years going by, this is themonth of Halloween, so be
careful with the gooks andgoblins out there, because
they're going to get moreprevalent as the month goes on.
Today we've got Mr Ray Cobb.
He's riding side saddle over onthe side car in the Harley
we're riding.
How are you doing, ray?
Ray Cobb (00:44):
I'm doing great Beautiful day down here today.
That great fall weather startto set in cool in the morning.
We got plenty of rain this lastmonth, so we're liable to have
a gorgeous fall down this way.
J Basser (00:58):
Well, I'm glad I like seeing these things get real
pretty.
Got a treat for you.
Today, folks, we've got ourresident instructor.
I guess her name is BethanySpangenberg.
She is valid for vet, she's theowner of the company and we've
been discussing some stuff hereover the last year or so about
DBQs and different disabilities,and today y'all need to listen
(01:22):
up real close because we'regoing to talk about the ears.
How you doing, bethany?
Bethanie Spangenberg (01:28):
I'm doing well enjoying this beautiful
sunset that we get a little bitearlier, and glad to be on this
side of was it Hurricane Heleneor Helen, what they're saying
Because we had some floodinghere in Southern Ohio and so I'm
glad to be on this side of thestorm Good.
J Basser (01:50):
Well, it was a rough time.
It still is a rough time.
My place is wiped out,especially North Carolina and
eastern Tennessee.
It's bad.
They say I-40 is going to beclosed until September of 2025
between Asheville and Knoxville.
Bethanie Spangenberg (02:07):
Wow, yeah, I saw some videos coming out of
there.
It's terrible.
J Basser (02:13):
Yeah, it is, but I hear today they have no money to
do anything.
I remember feeling they didn'thave any money.
They gave it all away, so Ihope that's not the case.
If it is God, what a mess.
Ray Cobb (02:32):
There's one little community up there in East
Tennessee up close toElizabethan.
They've lost three fire trucks,four police cars and two
ambulances in the flood.
And I know our county.
We gave them two police cars,two patrol cars.
J Basser (02:57):
Okay.
Ray Cobb (02:59):
To try to help, you know, so that they can at least
get around and do some stuff.
J Basser (03:04):
Is the department trying to get it, so they can at
least get around and do somestuff.
Ray Cobb (03:07):
Is that part of the Tri-City?
Well, it would be in theTri-City section yes, kingsport,
johnson City area.
Yep, yep.
J Basser (03:15):
I'm just trying to.
Ray Cobb (03:16):
Elizabeth is about.
Oh, I guess it's only about 20or 25 miles northeast of Johnson
City.
Okay.
J Basser (03:25):
That's close of Johnson City, okay, that's close
to eastern Kentucky.
Okay, well, guys, fair for them.
You send whatever you can.
You know I mean Costco here isalready out of water.
It's been at all down there.
So you know everything isgetting balled up.
But I also got the porch crackgoing on folks, so you think
things can get bad.
We're fixing that empty shelvesagain and things are going to
(03:47):
skyrocket.
So I hope people grow a gardenthis year because they're going
to need the vegetables.
Bethanie Spangenberg (03:54):
Hopefully we get the rain to support the
garden too.
J Basser (03:57):
We need the rain.
We also need to get somebody inthe gubber to put a stop to
that strike and put it back towork.
That's what needs to happen,All right.
Well, let's talk about the ears, Bethany, because we all need
to be able to understand thesituation with the ears.
We've got a couple of betsmissing in.
I know one gentleman.
(04:21):
He hasn't filed a claim yet,but I think he's fixing to.
I think he wants to hear aboutthe ears Well.
Bethanie Spangenberg (04:24):
I appreciate them attending and
hopefully they learned somethingfrom what we talked about today
.
If you are a new listener,we've been covering these DBQs
one by one each month.
I don't think from my standpointthese DBQs are talked about
enough because we want to cover.
Our goal in covering these iskind of talking about each
(04:44):
section and what the veteransshould expect and have prepared
for their condition, talk alittle bit about what each
rating decision means and justkind of have a better
understanding of how thisprocess works from the medical
expert side of things.
So not necessarily the most hottopics or the most
(05:05):
controversial stuff, sohopefully we can keep you a
little bit entertained.
So I'm going to jump into theEar Conditions DBQ.
This DBQ is nine pages long andit has to do with the inner ear
(05:25):
, the middle ear, the outer earand infections.
This is not specific to hearingloss and tinnitus or ringing in
the ears.
Those are separate.
But before we dive into eachsection I do want to talk a
little bit about anatomy andwhat some of these terms mean.
(05:46):
So when we?
talk about the ear and the earstructures, we reference them as
the external ear, the middleear and the internal ear.
So the external ear is the partthat you can touch.
We call that the pinna, andalso includes the ear canal.
(06:07):
That is considered the externalear.
Now, your eardrum, or what wecall the tympanic membrane, the
outer portion, is part of theexternal ear and it creates a
seal from everything else on theinside.
So there is not supposed to beany air or fluid coming from the
(06:32):
inside of the ear to theexternal portion, so that that
eardrum plays a large portion ofour hearing and protecting our
brain from any type of infection.
And protecting our brain fromany type of infection.
Now, the middle ear is thepressure system.
It has to do with theeustachian tube, which is
(06:54):
connecting the inner ear to oursinuses.
So when we change pressures orchange elevation, that
eustachian tube adjusts thepressure in the middle ear so
that way we're not having earpain.
So, for example, if you've everbeen on an airplane, you'll
(07:15):
feel your ears pop.
What you're actually feeling isthat eustachian tube adjusting
to the pressure and theelevation change.
So that's necessary in order toprotect the mechanisms for our
hearing.
Now, the internal ear is yourbalance center and it also helps
(07:37):
you to understand your position.
Now, when I explain how theinner ear kind of functions, or
the internal ear functions, I'mgoing to use a layman example, a
very simplistic example.
So if you're a medicalprofessional listening to me
discuss this, just know that I'mnot using technical terms.
(07:58):
So when you think of how theinner ear functions for balance
and position change, I want youto think about a snow globe and
the confetti or the glitterinside the snow globe.
So our internal ear functionsusing a fluid and crystals
(08:22):
within the fluid.
So if you take a snow globe andyou're not shaking it up right
now, but you're holding the snowglobe and you turn the snow
globe, which shifts the glitterto the bottom because of gravity
.
That is the same process thatoccurs when we change our
position.
So those crystals within ourear adjust to the gravity and
(08:47):
move to give signals about whereour head is positioned in space
.
So if you shake up that snowglobe, that is chaos in your
inner ear and that's where wecan start to get symptoms of
dizziness in your inner ear andthat's where we can start to get
symptoms of dizziness and wecan intentionally like as
(09:09):
children when we're on themerry-go-round, we can
intentionally trigger thedizziness symptoms by spinning
really fast right Makes us dizzy.
But as we get older we could bemore sensitive to that change
and it can create a disease.
And that's where we start toget some of our diseases known
(09:30):
or symptoms such as vertigo, thedizziness that we're not trying
to trigger or we get.
The most common one people talkabout is the benign positional
peripheral vertigo, or BPPV.
That's a big one that peoplelike to claim or even some
symptoms of Meniere's disease,and so we'll break down each
(09:53):
condition as we go through theDBQ.
But I really just wanted to putthat out there and that way
everybody understands thefunction of each section of the
ear.
Does that make sense?
The function?
J Basser (10:09):
of each section of the ear.
Does that make sense?
Bethanie Spangenberg (10:20):
Yes, it does.
Okay, All right.
So as we go on to page one, thesections here on page one are
the standard questions that wesee in every DBQ.
It talks about disclosing therelationship between the
examiner and the veteran, ittalks about what evidence was
reviewed and then it asks aboutthe diagnosis that is to be
addressed.
As always, I highlight thefirst box in the diagnosis
(10:41):
section, and the first box thatthe medical examiner can mark
reads the veteran does not havea current diagnosis associated
with any claimed conditionslisted above.
And this is where I emphasizethat a diagnosis is important to
the clinician in order tounderstand the relationship for
(11:02):
your disability claim.
So, while it may not be legallyrequired, it's a legal argument
If you don't have a diagnosis.
I will say that from themedical expert side of things.
If you have a diagnosis beforeyou go into that compensation
and pension exam, you're savingyourself so much time and so
much energy when it comes toyour disability claim.
(11:25):
It is absolutely recommendedfrom the medical expert
standpoint to go into your compand pen with a diagnosis.
So some of the diagnoses thatare listed on this DBQ are on
the top of page two.
Some of these medical terms mayring a bell to you.
(11:46):
So as I go through there, justknow that these are the
conditions that we're also goingto be discussing briefly today.
So Meniere's syndrome,peripheral vestibular disorder
this is where the vertigo fallsunder.
We have the benign paroxysmalpositional vertigo or the BPPV
that I mentioned.
We have chronic otitis externa,and that is the external ear
(12:13):
infection.
We have chronic superativeotitis media, so media is middle
, and so that is a chronicinfectious disease inside the
middle ear.
We have a chronicnon-superlative otitis media, so
it's more of a, rather than itbeing an infectious fluid.
(12:37):
It's a different type of likeoil almost that's in the middle
ear.
Then we have mastoiditis, whichis an infection of the bone,
and then we have otosclerosis,which is actually arthritis of
the bones inside the ear Part ofhearing.
(12:58):
There is vibration that occursbetween these itty bitty tiny
bones of the ear, vibration thatoccurs between these itty-bitty
tiny bones of the ear and youcan actually develop arthritis
in those itty-bitty bones fromvibration or loud noises and
it's interesting that even thoseteeny bones can develop
(13:19):
arthritis.
But that's what theotosclerosis is okay.
But that's what theotosclerosis is okay.
One other condition that's notlisted on this but is discussed
in the rating schedule istympanic membrane or that
eardrum perforation, and I justwanted to throw that in there
because it does not have arating, a disability rating,
(13:40):
meaning that it's listed withthe diagnostic code but it's at
a 0%.
It's not compensable.
The reason why I bring that upis because the eardrum
perforation can actually becommon for veterans, whether it
comes from an ear infection orsinus issues.
Even trauma can cause aneardrum rupture or perforation
(14:04):
and I just want to mention thatit is not compensable.
But you can get itservice-connected and then file
conditions that may havedeveloped secondary to that
eardrum perforation.
So I think that's important tobriefly mention on there as we
move into Section 2 of thesecond page.
This is the medical history.
(14:24):
We've talked about this withevery DBQ.
That is where the examiner canreview your statement or they
can ask you interview questionsto plug that information inside
the medical history.
Page three, the top of pagethree, talks about medications
that you may be taking for yourear condition, and then section
(14:48):
three is where we really startdiving into what rating
percentages apply to these earconditions.
Do you guys have any questionsso far about what we've talked
about or what I've brought upfor the DBQ?
J Basser (15:10):
That was just thinking .
Yep, three phases, you've gotthe outer ear, the middle ear
and the inner ear.
Is that the face of what you'resaying?
Ray Cobb (15:21):
Yes, that's what I'm saying.
J Basser (15:22):
Okay, so which one is the station, tube dysfunction
being the middle ear?
Bethanie Spangenberg (15:28):
That's going to be the middle ear.
J Basser (15:29):
Okay, that's what I was like.
Okay, it's time to wrap myburner in this, because I've
been fighting this stuff foryears.
Ray Cobb (15:37):
Okay, question real quick, bethany when they say you
have an ear infection, is thatmost of the time on the outer
ear?
Bethanie Spangenberg (15:50):
No, so when somebody says that's going
to be the middle ear.
So what normally happens is themost common term, like when you
hear young children have adouble ear infection.
Most commonly what that is isthey've looked inside the ear
canal and they can see fluid andirritation of that eardrum.
Now, because that eardrumcreates a separation between the
(16:12):
outside world and the insidesinus cavity, the fluid is
actually and the infection isactually inside of that metal
ear.
The interesting part is thatthe eustachian tube, which
controls the pressure and issupposed to allow air in and out
of that middle ear, what canhappen is bacteria from the
(16:35):
sinuses can go up into thateustachian tube and irritate
what's inside the middle ear.
So most often when we havethese middle ear infections or
young children have earinfections, it's not necessarily
that the ear is not functioningcorrectly.
It's that eustachian tubethat's not functioning correctly
(16:57):
and that's coming from sinusirritation.
So sinusitis, allergies, coldviruses.
(17:18):
So sinusitis, allergies, coldviruses those things are what
contributes to dysfunction ofthat eustachian tube and then
prompts bacteria into the middleear and causes those ear
infections.
J Basser (17:29):
So that's a good question because now we're
connecting dots of rhinitis,sinusitis, ear infection, that
kind of thing.
So that's a good question, butthat usually requires tubes to
be placed in right.
It usually requires what Tubes,tubes?
Bethanie Spangenberg (17:49):
Ear tubes, yeah, tubes, yeah.
So ear tubes can becontroversial, especially in
your younger children, becausesometimes they're really.
Some clinicians believe thatthey're not treating the
underlying issue.
They're not treating theallergies or the sinus issues,
or whether it's environmentalallergies or symptomatic
treatment of viruses, so they'renot getting control of that
(18:09):
inflammation within the sinuscavity which is causing that
tube to malfunction.
So, some clinicians believe thatear tubes are a band-aid on the
problem and they're not trulyaddressing the issue, and ear
tubes can then go on and causescarring, which causes hearing
loss and issues within you knowas they age.
(18:32):
Some clinicians believe thatthey should be treating the
underlying issue rather thanjumping to ear tubes.
I don't know that's a topic.
That's a whole other show, Ithink in and of itself.
But as adults, I have seenadults get ear tubes because
they can't get control of thesinus issue and it leads to
(18:53):
frequent ear infection.
Ear tubes as adults aredifficult because you don't have
the healing and recovery thatyou have in your childhood.
So ear tubes as adults you'rereally taking a risk of hearing
loss because you don't have thehealing and recovery that you
have in your childhood.
So ear tubes as adults you'rereally taking a risk of hearing
loss that may develop followingthe ear tube placement.
That's a discussion betweeneach clinician and each patient
(19:18):
with their provider.
J Basser (19:20):
How about 17 over 20 years?
Bethanie Spangenberg (19:24):
That can cause some hearing loss.
J Basser (19:26):
What did you say?
Bethanie Spangenberg (19:28):
Exactly so .
While we're on the topic of theear infection, like when
somebody goes in and says an earinfection, the only way that
you're really going to get anexternal ear infection is from
something irritating the skinsurface, Because the eardrum
(19:51):
does create a barrier betweenthe outside world and the inside
of the sinus cavity.
Then anything that is on theoutside of the eardrum that gets
infected is either coming fromtrauma of the skin, like people
putting paper clips in their earto get something out of their
(20:11):
ear, or somebody taking theirfingernail and scratching their
ear by accident, like somethingitched and then they scratched
their ear.
So whenever we talk aboutinfections of the external ear,
it's most commonly going to becoming from some type of trauma
to the skin surface itself.
Okay.
(20:33):
So when we jump to page three,section three, this is where a
lot of the ratings are Like.
This is the dense area of whereour rating percentages come
from for vestibular conditions,and when we talk about
vestibular conditions, we'retalking about conditions of the
internal ear that affects ourbalance and our position.
(20:55):
So when I talk about, or Imentioned the peripheral
vestibular disorder, okay, theperipheral vestibular disorder,
okay, that's what they arereferencing in Diagnostic Code
6204, but that's also commonlyvertigo okay.
(21:18):
This is also the benign,paroxysmal positional vertigo
which we get.
A lot of veterans that havethat diagnosis and they claim
that secondary to a conditionthat also falls under diagnostic
code 6204.
Now, clinically, meniere'ssyndrome is also a peripheral
(21:39):
vestibular disorder that affectsthe internal ear, but it gets
its own rating schedule and itsown diagnostic code under 6205.
And so as I go through Section3, I'm going to kind of talk
about what each percentage meansfor these conditions.
(21:59):
Okay, so Section 3 asksspecifically about hearing
impairment with vertigo andthey're asking that because of
Meniere's disease.
Now I guess I should explainthat Meniere's disease does
affect the internal ear but italso creates symptoms of hearing
(22:24):
loss and ringing of the earsand Meniere's disease when a
veteran gets diagnosed with itit's something that they have
been dealing with for a while.
That usually takes severaldoctor's visits in order to
capture that diagnosis.
Often we see patients will comein and they will talk about
(22:46):
having some hearing issues andprimarily the vertigo complaints
, the dizzy that you know.
They feel like the room isspinning and they may develop
some nausea with that dizziness,and so when they come in, the
primary care doctor or themid-level practitioner may try
(23:08):
to do a physical examination,they may try to do some what we
call maneuvers in order tonarrow down what may be
occurring, be occurring.
So there's some clinical toolswe can use as far as like
(23:28):
position change to trigger thesymptoms, or head movements to
trigger the symptoms, and ifthose become positive, then we
can say, okay, well, we aresuspecting that it may be this
condition, and then we give amedication or we throw a
medication out and we say okaywe're going to try this
medication.
If it helps, great.
We'll have you follow up in acouple of months to see if
anything changes.
So if the veteran or thepatient says, well, it went away
(23:53):
with that medication, sometimesthey don't come back, and then
a few months down the line theymay develop another episode, and
so it can typically take awhile before a veteran or a
patient narrows down thediagnosis of Meniere's disease.
What happens is those episodesbecome more frequent, or they're
(24:14):
not helped with medication, orthey're persistent, and so it
can take a while for a veteranto actually capture the
diagnosis of Meniere's.
They are often referred to aspecialist, either an ears, nose
and throat specialist or a teamof an ENT specialist and an
(24:35):
audiologist, before they trulyget the workup that is necessary
to diagnose them with Meniere'sdisease.
With Meniere's, if you havehearing impairment and a vertigo
less than once a month, you geta 30% rating.
The next symptom for Meniere'srating is hearing impairment,
(24:59):
with attacks of vertigo anddifficulties with gait or
unsteadiness.
If you get that one to fourtimes per month, it's a 60%
rating for Meniere's.
If you get it more than onceweekly, it is a 100% rating for
Meniere's.
At Valor for Vet.
That is a big one that veteransare trying to service connect
(25:21):
once they capture the diagnosisof Meniere's because of that
high rating and it can bepersistent and overwhelming and
cause the nausea and vomitingand discomfort with the disease
because of the symptoms.
So, continuing with Section 3of the symptoms, tinnitus is
(25:42):
mentioned on there.
That's really just to promptthe additional DBQ.
Hearing loss is also on thesymptom questionnaire and that's
again to prompt the other DBQfor the audiologist to conduct
for hearing loss and tinnitus.
(26:03):
And then the other question onthe symptom section for section
three is vertigo, which we'vetalked about significantly, and
if you have vertigo it is a 10%rating.
Or you have vertigo with thestaggering symptoms or the gait
(26:26):
unsteadiness, the staggeringsymptoms or the gait
unsteadiness, those together area 30% rating for vertigo or the
vestibular inner ear disorders.
So if you have a vestibular orinner ear condition, often the
symptoms are the dizziness andsome unsteadiness on your feet
(26:47):
because of the dizziness.
So that's a 30% rating forthose conditions.
So there could be a little bitof meat on the bones, I guess,
for those conditions if you getthem service connected.
Any questions about the innerear?
J Basser (27:09):
As far as unsteadiness , I mean, if you've got that
condition, you're in steadywalking, you're going to need
help transferring and thingslike that where a person falls
off or a dependent is based onsomething like that.
They can.
Bethanie Spangenberg (27:21):
They can, depending on the frequency of
the symptoms.
If it's something that occursonce or twice a year, maybe not,
but if it's something that ispersistent and you require the
assistance of another because ofit, then absolutely.
Now, if we move on to Section 4, this is to do with the ear
(27:44):
infections of the external ear,with the ear infections of the
external ear.
Okay.
So section four.
It covers infections andinflammatory ear conditions.
But primarily the ratingschedule for this section is for
that chronic external earinfection.
Okay.
Now for you to get a 10% ratingfor an external ear infection
(28:31):
that is chronic, you have tohave swelling, dry and scaly
skin, drainage from the earcanal, itching and requires
frequent and prolonged treatment.
I don't know that I've everseen an external otitis ear
infection have all of those andthat is a 10% rating.
So that's not a for me.
It's not a realistic thing tosee in the clinic or for a
disability rating thing to seein the clinic or for a
(28:53):
disability rating.
Section four continues to askquestions about
infection-related conditions andthat's to prompt another DBQ,
for example, bone loss of theskull.
You can get a disability ratingif the ear infection goes into
the bone behind the ear.
That is what we callmastoiditis and sometimes with
(29:15):
mastoiditis they have to go inand remove that section of bone
because there is chronicinfection in there.
I have seen that a few timeswith patients who have.
Normally it's not likesomething that occurs because of
chronic otitis media, but it'ssomething that occurs as like a
(29:36):
random fluke.
They get a really severe earinfection one time and it just
decides to seed into the bonethat's close to that ear
infection and then they go inand they have to have part of it
removed.
Once you have mastoiditis orinfection in that bone area,
it's actually a pretty seriouscondition because it is so close
(29:56):
to the brain.
You start to worry about theinfection causing issues with
the area around the brain oreven getting into growing to
cause pressure in parts of thebrain.
So once you get mastoiditis orinfection into the bone, it's a
pretty significant conditionwhere the individual has
(30:17):
experienced, you know, somechronic issues to lead up to
that.
So that actually covers Section4 for infection.
Do you guys have any questionsabout that?
Ray Cobb (30:32):
No, is it hard to get those infections cleared up?
Bethanie Spangenberg (30:37):
If you don't treat the underlying issue
absolutely with mastoiditiswhen it gets into the bone.
If you catch it early enough,iv therapy can usually help.
You always have to watch forrecurrence in case the
antibiotics didn't get all ofthe bacteria.
(30:58):
But once it's into the bone andit's not responding, it can be
I mean, that's where they gointo removing the bone itself
because they're having so muchissue.
To control it.
It can be difficult at thatpoint.
So moving on to Section 5, onpage 4, section 5 talks about
(31:22):
surgical treatment.
This is just a genericfill-in-the-blank.
What kind of surgery?
When did it happen?
Was it left or right side?
What was it for?
And then I ask about anyresiduals related to surgery.
And then we jump to page five.
Page five and six are bothdedicated to the physical
(31:44):
examination, to the physicalexamination.
Now I will say that for most ofthe ear conditions that are
covered for the CBQ a physicalexamination is not required.
So if I look at the veteran'sfile and I see that he has a
diagnosis of Meniere's, thelikelihood of me seeing anything
(32:08):
related to that Meniere's bydoing a physical exam is low,
especially if they're not havingactive symptoms for that day.
So because Meniere's affectsthe inner ear.
I cannot see the inner ear bydoing a physical examination.
The only way that we can reallyassess the inner ear is by
(32:30):
doing images and doing maneuversor tests in order to capture or
trigger those symptoms.
So whenever a veteran goes infor their compensation and
pension examination they may nothave a physical exam at all for
the ear conditions that they'reclaiming.
(32:51):
So, for example, the first partto examine is the external ear.
The external ear as it relatesto Meniere's has no value for me
to look at it, so they may notdo the exam.
Has no value for me to look atit, so they may not do the exam.
(33:12):
The next section is for the earcanal.
Again, for some of those innerear conditions the canal does
not play a role in that diseaseprocess, so they may not look
into it.
And then we have the tympanicmembrane or the eardrum that the
examiner is to look at.
And there is an option here forthe examiner to say let me read
it word for word to you.
It says let me see, oh, exam oftympanic membrane is not
(33:42):
indicated, or exam of the earcanal is not indicated.
So they have the option ofmarking that on the DBQ and
moving on On page six, this isthose specific maneuvers that I
was talking about, that aretools used to help us suspect a
diagnosis.
(34:10):
So normally if a patient comesinto the clinic and complains of
dizziness and I'm suspectingsome type of inner ear complaint
, I will watch them walk, butthey may not have an abnormal
walk.
Sometimes they may have somestaggering that we talked about,
but that's not always presentfor a compensation and pension
(34:33):
exam or a visit into the clinic.
Normally that's something thatthey say hey, I'm having trouble
walking, I kind of fell intothe wall at home or at work.
That's normally what we arehearing in the clinic, not
something that we see firsthand.
There's a test called theRomberg test which has to do
(34:54):
with the arm change during anexam.
Basically the individual closestheir eyes, they stick their
arms out inside of them withtheir palms up and they just
hold them there and sometimes wecan see an arm start to drift.
That is more used in the clinicfor a neurologic condition than
(35:16):
it really is for an inner earcondition.
But it's on the DBQ and it's atool that can be used to kind of
support a diagnosis that may befound related to an inner ear
condition.
The next one is a Dix-Hallpiketest and I'm not really going to
explain that because it can bedifficult, but it's a position
(35:39):
change trying to trigger some ofthat dizziness that the patient
may be experiencing that thepatient may be experiencing.
And then there's a limbcoordination test where the
patient can take their indexfinger and they touch the
examiner's finger and then touchtheir nose and the examiner
moves their finger and thatpatient has to touch the tip of
(36:01):
that finger and their nose again.
So some of these things youguys have made down in the
clinic, these are just tools tohelp us kind of narrow down the
diagnosis For compensation ofpension purpose.
They have no value but they aredocumented on the physical exam
.
So I think that's really tomake the clinician feel better
about discussing an inner ear orear condition rather than
(36:25):
coming in and asking aboutsymptoms and then walking away.
I really do, because it has novalue when it comes to a rating
decision.
Any questions about the physicalexam?
Ray Cobb (36:38):
No.
J Basser (36:41):
I've been through quite a few of them and you're
right exactly what that is, yeahright, exactly what it is.
Bethanie Spangenberg (36:47):
Yeah, it's actually if um even like with
someone that you're concernedwith, um like their brain
function, if you're concernedwith a stroke or some type of
dementia or alzheimer's, or evenlike a tumor, the testing that
is done, some of the arm drift,or that Romberg test, the finger
(37:11):
to nose those are prettystandard things, even with the
TBI.
If you have a concussion orwe're in a motor vehicle
accident, the examiner may dosome of these similar
examinations in the clinic toassess how the brain is working.
And again, the inner ear is soclose to the brain that we
(37:33):
really have to use these astools to support our clinical
decision-making.
So if we move on to the DBQ,we're looking at page 7.
We're looking at section 7.
It has to do with tumors andneoplasms.
Since we've covered these DBQs,I really haven't laid heavy on
the tumors and the neoplasms,mainly because the thought
(37:56):
process for each area is aboutthe same.
So it has to do with whetherit's malignant or benign and
what kind of disruption thattumor or growth has created on
the body.
There's nothing specific in therating schedule for tumors and
what we call neoplasms or growthas it relates to the ear
(38:20):
specifically, and if it was, Iwould break it down, but there's
nothing specific to the earconditions as it relates to any
type of tumor or growth.
Moving on to Section 8, we'reactually on the home stretch
when it comes to the DBQ.
Section 8 is the blanket areafor the clinician to discuss any
(38:41):
other physical findings orcomplications that they want to
discuss that they found duringtheir time with the veteran.
Also, the space there or thequestionnaire regarding scars,
which we have discussedpreviously.
Section 9 on page 8.
This is important.
(39:01):
This is the diagnostic testingthat has been done.
There is a section in the CFRthat talks about requiring
objective tests in order to givea compensable rating for any
type of inner ear disease.
So if a veteran is claimingvertigo or the BPPV or MeniereS,
(39:28):
they are going to have toprovide the workup and the test
that show the objective datathat they have that condition.
So that's important.
And, rounding out the DBQ, onpage 9, we're looking at other
testing that may have been donefor the veteran's condition.
(39:52):
Section 10 is that functionalimpact.
As always, I emphasize that youput any type of functional
impact, any type of symptom thatprevents you from doing your
regular function at work or athome is important to document.
(40:14):
As John previously asked aboutaid and attendance, you want to
talk about those limitationsthat you have with the condition
in your statement.
The clinician may not alwaysask about what your functional
impairment is.
They may look at it and say,okay, well, the veteran has told
me about all these symptoms.
(40:34):
That's not going to keep himfrom working, that's not going
to keep her from working, sothey may mark no, that you don't
have any functional impairmentand move on.
So as always, I emphasize, youneed to put that information
into a statement and supportiveclaim to go with your disability
claim.
The last two sections we haveSection 11, which is remarks and
(40:58):
open space for the clinician tomake any comments, and then the
last section, section 12, isthe examiner's certification and
their signature asking aboutyou know their certification,
their license number, thingslike that.
Any questions about the EAR DBQ?
J Basser (41:21):
You heard your Latin clear.
Bethanie Spangenberg (41:27):
I would say that this DBQ is pretty
straightforward.
If the veteran goes in to talkwith the clinician in person,
they can be in and out the doorin 30 minutes with this
examination it would take theclinician maybe 45 minutes to an
hour to do the DBQ and answerany type of medical opinion that
(41:49):
would go with this exam request.
J Basser (41:55):
Well, you know, the most common I guess like the
most common disability withinthe VA system, is public
analysis right.
Bethanie Spangenberg (42:02):
Yes, absolutely Okay.
So, Absolutely Okay, you know,I'm waiting for them to.
J Basser (42:14):
I wonder if they will ever change that?
Bethanie Spangenberg (42:15):
Because they have recently.
If you look at the changes thatthe VA is trying to make as it
relates to disability anddisability ratings, is they're
really trying to put objectivematerial into these conditions
and objective informationbecause they don't want to
believe the veteran and theyfeel like a lot of the
conditions the veteran may beexaggerating.
So if you look at the changesthat they're making, that we've
(42:37):
even talked about, is they'retrying to objectify everything
and they're trying to requirethat there are tests done or
things to prove that they aresuffering from these conditions.
So tinnitus, that is onecondition that is so common,
especially in our militarypopulation, but there is no
(43:00):
objective testing to prove thatthey have this condition.
So I'm interested if they evertouch it?
And if they do, what are theygoing to do?
J Basser (43:13):
I mean I can hear it.
I may not be able to hear it,but I can hear it.
And you know it's prettyterrifying.
I mean I've seen it drivepeople to suicide.
Ray Cobb (43:23):
Yes.
J Basser (43:25):
So pretty bad stuff yes.
Bethanie Spangenberg (43:28):
It's actually interesting to see
because tinnitus is one of thosethings that can affect how a
person communicates and it cancreate a barrier between you
know the veteran that has thecondition and how they interact
in day-to-day life and how theyinteract in day-to-day life.
So I've said this before and Isay this a lot to the people
(43:49):
that I communicate with, is thatif I didn't see it firsthand, I
wouldn't believe it, and so alot of the things that I watch
my veterans suffer with I trulybelieve.
That's why I do what I do isbecause as a young family, I
don't feel like my husbandshould be suffering through some
of the things that he'ssuffering with, and tinnitus and
(44:23):
hearing loss is one of thosethings that you don't.
I guess for myself I wouldn'thave expected to deal with at
this age, because we go to thesoccer game my son's soccer game
and he hears the crowd aroundhim and he doesn't realize that
he's as loud as he is and hewill make comments and then my
elbow goes into his side because, hey, you don't realize how
(44:43):
loud you're saying thesecomments.
You can't say those comments Iget that a lot.
J Basser (44:49):
He gets those comments .
Bethanie Spangenberg (44:49):
I get that a lot.
J Basser (44:50):
It's the elbow, I get that a lot.
I mean, yeah, you don't knowhow loud you are.
You know because you don't knowit.
You know, and it's like mywife's father is, uh, almost
completely deaf.
He's a coal miner and, uh, he'shad hearing aids and all this
stuff for years, butoccasionally he can hear.
Okay, we were trying to get himheadphones and watch TV and
(45:11):
things like that.
But he talks, just like youknow, he's really loud.
Pretty sad, but she looks at melike yes, yes, every time I say
something Shut up, shut up.
Bethanie Spangenberg (45:26):
It's interesting too, because our
children don't appreciate whatis normal as far as a volume to
talk, and so our children, Ieven have to remind our children
like hey, don't talk so loud.
So then I have my son, whodoesn't talk loud at all because
I keep telling everybody tostop talking so loud.
And then you have my olderdaughter who talks really loud.
(45:47):
I'm like, hey, you're too loud.
And so there is nounderstanding in our household
of what is socially acceptablevolume in each you know social
setting, and so it's kind offunny.
J Basser (46:03):
You know how it all, you know you got me thinking
what is the VA going to do withthese conditions?
That there's no test todetermine what it is.
Cannabis is one, but you knowthe biggest one is mental health
.
There's no physical test formental health.
You know Well from what I'veseen so far.
Bethanie Spangenberg (46:22):
what I've seen so far is they're not doing
a good job and I have, you know, made it a point to be more
proactive and watching whenthese conditions open for
comment.
I really feel like you know,being in this role or this very
small area of expertise, is thatI really need to use my voice
(46:44):
to talk about some of what isclinically appropriate and their
goal of requiring objectivefindings.
We talked about the GERD changesand I don't agree with what
they've done on the GERD changes, because there is other ways to
prove objectively that anindividual suffers from these
(47:07):
conditions.
And to require a medicalcondition to be so severe that
it creates complications thatare life-threatening
complications before youcompensate an individual, I
think that's, I don't thinkthat's fair, I don't think
that's right, I don't thinkthat's realistic and you know
(47:30):
idealistic, I guess.
How it affects the workforce ortheir occupational duties or
(47:54):
their functional capacity, Well,GERD creates occupational
impairments and there's the dataand the studies out there and
they don't use those as areference.
They want to use literature thatis 20 years old and say well,
this is how we're justifying itliterature that is 20 years old
and say well, this is how we'rejustifying it so yeah, and so I
(48:16):
feel like I need to be moreproactive in addressing some of
their proposed changes.
J Basser (48:20):
Question on the group last week.
Question on the group.
Last week I was reading thatsomeone said that a lot of VA
providers know a veteran's got acondition and they're recording
in their record but they willnot actually make an official
diagnosis of that condition.
Do you know what makes themreluctant to do that?
Are they afraid the vet's goingto go out and file a claim for
it, or what?
I see that a lot.
Bethanie Spangenberg (48:46):
I can see it being that way.
They're worried about gettingtied up into the whole
disability process.
And so, you know some of theclinicians at the VA, they kind
of get burnout on veteranspushing the latest and hottest
issue.
Veterans pushing the latest andhottest issue.
(49:07):
You know, there's been times inthe past where I've always, you
know, encouraged thoseproviders to just keep their
head down and stay out of themess, Just document the
discussion that you've had anddon't get tied up into what they
are trying to do.
You have to make what isclinically appropriate for your
patient and not what a veteranmay be pushing to do.
(49:31):
And I think we talked aboutthis briefly, about how the GERD
changes are now going to pushthese veterans to want to see
the GI specialist.
Ray Cobb (49:43):
And.
Bethanie Spangenberg (49:43):
I don't necessarily disagree with that
as long as it's clinicallyappropriate.
And I don't necessarilydisagree with that as long as
it's clinically appropriate.
And so that's again.
I tell the clinician.
I know that it's stressful, Iknow it creates a lot of extra
appointments in your workday,but keep your head down, stay
out of the legal mess, documentthe discussion as you would any
(50:05):
other time, and do what'sclinically appropriate.
You cannot allow the disabilityrating schedule and the
political changes to impact yourclinical decision-making.
And it's hard to do, it can beoverwhelming at times, bethany
one thing I've noticed where Igo.
Ray Cobb (50:27):
here the doctors are actually doing they're saying
what needs to be said, butthey're not putting down the
diagnosis itself In the littlesquare where it says your
diagnosis.
They leave that blank.
Now, up above that, they'retelling you know all the
conditions, all the things thatare going on, and then don't do
(50:49):
that.
And then when the guy goes andfiles his claim, they come back
and say well, you didn't have adiagnosis for it, so there's a
couple things that I've seenwith that.
Bethanie Spangenberg (51:02):
So for us in the clinic and how it relates
to disability, it can be not onthe same page.
They're not always on the samepage.
So for me, like in the clinicwhen I would do my charts or
when I do my charts, there's somuch you have to have for
(51:25):
billing purposes.
There's so much you have tohave for billing purposes.
(51:51):
And that's really where adiagnosis code, the diagnosis
portion, so when it comes to aveteran having a diagnosis, it
doesn't require that it is in abilling code, it requires that
it's under the clinician'streatment plan.
So there's a section underassessment and plan in the note
(52:16):
that the clinician will lineitem the diagnosis and maybe
after that diagnosis they willsay their treatment plan.
And so it can be difficult tokind of argue that between the
clinician side and the legalside because they're not putting
it in the diagnosis section fordisability purposes.
(52:42):
Are you following?
what I'm saying yeah exactly Allright the difference is that
basically the note is a freetext versus the billing is a
formal code.
So sometimes the clinician willput what is required for billing
purpose and a formal code, butthey will free text all the
(53:06):
other diagnoses in the note.
So, for example, I would see apatient who would have 23
diagnoses.
I never put all 23 diagnosesinto my insurance bill because
the top three are the only onesthat mattered.
So I would click or insert twoor three codes that would
(53:28):
capture the billing for theinsurance and then the other 19
diagnosis would be in my freetext section of my note and so
they don't correspond.
And when you go to get yourblue button records, the only
ones that fall under thediagnosis section is what the
clinician has put in for billingpurposes.
(53:49):
Now if you're talking about theclinician having a series of
symptoms that's consistent withthe diagnosis, you know, I would
not want to believe that theclinician is trying to gatekeep
that veteran from getting whatis entitled to him.
I wouldn't believe that's so.
That I would believe is eitherclinician inexperience or
(54:10):
they're requiring another visitto confirm the diagnosis.
J Basser (54:14):
Okay, Beth, you just learned something very important
right there.
Anytime you're looking at yournotes and you're trying to see
what's what, pay very specialattention.
It doesn't matter what iswritten in the upper part of the
document.
Go down toward the bottom andyou'll see bottom and you'll see
the assessment and you'll seethe treatment plan.
That is the bread and butter.
Bethanie Spangenberg (54:33):
Yes.
J Basser (54:33):
According to yes.
So you know that's somethingyou guys.
It makes it easier to look atthings when you guys so Well
we'll get, if you're looking forsomething you'll find it.
Go ahead, betsy.
Bethanie Spangenberg (54:49):
We'll get veterans that try to give us the
discharge instructions as proofof treatment for a condition
and we can't accept those asproof because it doesn't open or
allow for us to see what theclinical thought process was and
what the assessment and plan is.
And so when somebody gives usthose discharge instructions
it's like okay, this is patientverbiage.
So when somebody gives us thosedischarge instructions, it's
(55:10):
like okay, this is patientverbiage.
These discharge instructionsare specifically targeted to a
10th grade level for thatpatient to understand what their
diagnosis is and what they needto do to treat it.
It has from a compensation andpension and medical expert side
it has little to no value for usto understand what happened at
(55:30):
that clinical visit.
So we need to see thattreatment record and what that
clinician has put into theirassessment and plan of the
clinical record.
So it has value not only forthe claim and for the veteran to
look at but also for themedical experts.
So you really need to get thoseif you're wanting, you know, to
capture a private opinion.
J Basser (55:54):
And, if need be, guys, you've got a situation like
that and you don't think youhave a diagnosis, you can look
at it.
It's always good to have asecondary backup plan just in
case, and there's a companycalled Vow valid for vets.
You can call up and send theinformation to them and join
their portal with let's just lethim look at your paperwork, see
(56:15):
if you can't work out anindependent medical opinion with
her and her her team, becausethey're good at what they do
well, thank you for the plug,and we're actually going into
our 10th year and we're lookingto celebrate 10 years in the
year of 2025 that we've beendoing what we do and from the
(56:36):
team approach that sets us apartfrom everybody else.
That's what it takes.
It takes a team to build it.
It takes a team to build it.
It takes a team to keep itgoing too.
That's a lot of work, so that'sgood.
I want you to give everybodyyour contact information,
bethany, so in case anybody'slistening out there and wants to
(56:59):
contact you and maybe reach outand touch you and get an IMO,
what's the best way to get ahold of you and the website, and
I'm both.
Tell me the best way to get ahold of you and the website.
Bethanie Spangenberg (57:09):
So our website is Valor V-A-L-O-R.
The number four vet V-E-T dotcom.
You can plug it into Googleclose as you want, and our
website will pop up, or you canplug it into the URL directly.
There's a lot of informationand tools there that you can use
(57:30):
and view to see how we may beable to help you.
It has a process there for youto understand how we work, and
then you can always call us888-448-1011, if you just have
questions and want to talk tosomebody.
We have veterans on our teamthat have been with us for a
while that can help youunderstand how we function and
(57:51):
how we may be able to help you.
J Basser (58:00):
Well, that's a good one.
That's pretty good.
Reach out and touch them folks.
If you need help, they're thereto help.
So it's, uh, you know it's agood thing.
Plus, their rates are really,uh, really really competitive.
They're not very expensive asfar as doing things like that.
They're, uh, you know, good.
Imo is worth the weight in gold, you know, because a lot of
(58:23):
these examiners don't want togive you a diagnosis.
Of course they do have thediagnosis, but it's hard to get
it out of them.
It's kind of like squeezingblood out of a tomato.
But other than that, we've gotabout a minute left.
Bethy, I want to thank you forcoming on again, as usual.
And we'll get together nextmonth and we'll have another
(58:44):
subject to talk about.
I don't know what it is yet,but I'm sure you'll think of
something good.
Bethanie Spangenberg (58:51):
Well, I actually have it in mind.
I think we need to keep goingwith the ear conditions or the
upper respiratory, I guess, ears, nose and throat Transition
into sinusitis and rhinitis,which is a good one, okay, well,
we'll stay with the anatomy ofthat situation and go that way.
J Basser (59:11):
Well, thank you for coming on, buddy, and I
appreciate your help, man.
Ray Cobb (59:14):
Yeah, no problem, glad to be here and Bethany thanks
Every time she's on.
I learn a little something elseabout my own medical stuff, you
know, and so it's a big help.
J Basser (59:25):
I put that on there every time she's in.
I said join us, as I learnsomething every time Bethany
appears on the show.
Ray Cobb (59:31):
Yeah.
J Basser (59:31):
Well, listen.
That'll be it for today.
This is John, on behalf of Rayand Bethany, and the Exposed
that Radio Show will be signingoff for now.
You have been listening to theExposed that Podcast.
Any opinions expressed on theshow are the opinions of the
guest speakers and notnecessarily the opinions of
Expose that, exposethatcom orBlogTalkRadio.
(59:53):
Tune in next week for anotherepisode of the Expose that
podcast.
Thanks for listening.
Ad (01:00:05):
You have to celebrate your wins.
We've won the Mint 400, andI've celebrated that win for
weeks.
But then we had to focus andmove on.
Dustin Jones,championship-winning Can-Am
off-road racer.
Can-am's the same the most racewins in all types of terrain
with the Maverick X3.
But then they focus and move onthe Maverick R 240 horsepower
in the first, seven-speeddual-clutch transmission.
(01:00:27):
This thing's a game-changer.
We celebrate those wins, butnever for too long.
The Can-Am Maverick X3 andMaverick R Visit CanAmOffroadcom
.
In the world of architecture,engineering and construction,
every detail counts.
That's why over 3 millionprofessionals trust Bluebeam for
PDF markups, digital workflowsand project collaboration.
Whether you're an architect,engineer or project manager,
(01:00:51):
bluebeam's easy-to-use softwarehelps you communicate clearly,
collaborate in real time and getmore done faster.
And the best part, you can tryBluebeam for free for 14 days,
no credit card required.
Visit bluebeamcom today.
Popular Podcasts
Are You A Charlotte?
In 1997, actress Kristin Davis’ life was forever changed when she took on the role of Charlotte York in Sex and the City. As we watched Carrie, Samantha, Miranda and Charlotte navigate relationships in NYC, the show helped push once unacceptable conversation topics out of the shadows and altered the narrative around women and sex. We all saw ourselves in them as they searched for fulfillment in life, sex and friendships. Now, Kristin Davis wants to connect with you, the fans, and share untold stories and all the behind the scenes. Together, with Kristin and special guests, what will begin with Sex and the City will evolve into talks about themes that are still so relevant today. "Are you a Charlotte?" is much more than just rewatching this beloved show, it brings the past and the present together as we talk with heart, humor and of course some optimism.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.