Attachment H1 - Example of Clinical Appeal.pdf

CASE ID

CLINICAL APPEAL REPORT

Case ID:

Patient Name:

Event date(s) to be reviewed:

Episode of Care:

Practitioner to be reviewed:

Credential: MD

Specialty: Psychiatry

SPECIFIC QUESTIONS FOR REVIEWER:

Does the Veteran meet the clinical eligibility requirements for the Caregiver Support Program?

If the Veteran does meet the clinical eligibility requirements for the Caregiver Support Program, at what Tier Level Rating (1, 2, or 3)?

SPECIAL INSTRUCTIONS:

Documents provided:

1. Caregiver Documents (2)

2. Clinical Eligibility Document from Denver assessment team (1)

3. Local-) appeal decision documents (5)

4. Templates for Clinical Eligibility and Scoring (2)

REVIEWER FINDINGS:

This patient presented with :

1) headaches; 2) post-traumatic stress disorder (PTSD); 3) abnormal movements (subsumed under PTSD); 4) irritable bowel syndrome; 5) non-epileptic seizure disorder (which was actually a conversion disorder); 6) dementia (although the patient's traumatic brain injury did not appear to have been labeled, although clinically assessed).

A neuropsychological report was received dated XXXXX. This diagnosed PTSD and Tourette's Disorder (labeling the movement disorder Tourette's and not a conversion disorder). There also was a diagnosis of neurocognitive impairment consistent with a traumatic brain injury. There was a consideration of a seizure disorder, but there was no electroencephalogram (EEG) information to consider a different diagnosis from the non-epileptic seizure disorder (conversion disorder).

A neuro-optometric vision rehabilitation evaluation found no impairment in visual acuity. However, there did appear to be functional and perceptual difficulties in "eye teaming ability". Visual rehabilitation was suggested.

A vestibular diagnostic evaluation was provided which suggested "mixed peripheral and central vestibular pathology." There was a proposal to consider vestibular rehabilitation therapy (VRT).

The patient "may be considered a fall risk."

Attachment H1: Example of Clinical Appeal

CASE ID

However, the veteran's clinical notes from XXXXX were reviewed which discussed the patient's caregiver status and the relevance of the service connected versus non-service-connected requirements for the Caregiver Support Program. Critical reviews that were carefully crafted were in evidence from Dr. XXXXX dated XXXXX (psychiatry) and by Dr. XXXXX dated XXXXX (neurology). Dr. XXXXX outlined the patient's symptoms as related to PTSD and made an affirmative diagnosis of PTSD which was consistent with the veteran's 100% service-connected status. However, in the reviewer's opinion, the disabling symptoms for which the Caregiver Support Program is being requested included: tics, unsteadiness, and memory issues. There appears to be no argument that PTSD symptoms qualify for or meet the three criteria necessary for Caregiver Support. This reviewer agrees with the assessment on XXXXX that in particular, the primary criterion #2 was not met on the basis of PTSD.

There also appears to be both neurological and psychiatric agreement that the tics, vocalizations, and memory elements are not integral elements of PTSD. There also appeared to be VA assessment that the patient did not meet criteria for service-connected traumatic brain injury. If the elements of tics, vocalizations, unsteadiness, and vestibular and ocular findings are adjudged to not be service connected, and it appeared that they would not be so unless tied to PTSD, then they do not become symptoms under consideration for VA Caregiver Support Program, whether caregiver support might be clinically indicated or not.

Dr. XXXXX in his note of XXXXX opines that this veteran’s conversion disorder (which could include non-epileptic seizures, tics, and memory impairment) are sequelae to the patient's PTSD.

It is not clear to the reviewer that this was accurate to a reasonable degree of medical certainty.

Conversion disorders can develop at any time in the life cycle. They do not require a prior diagnosis of PTSD and this reviewer knows of no peer-reviewed paper reporting a proven connection between PTSD and disorders such as non-epileptic seizures or tics. These two diagnoses are independent in Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM V). This reviewer believes that the connection between the two for this veteran was not proven to a reasonable degree of medical certainty. Since these "disabling symptoms” appeared to require caregiver support cannot be linked to the service connected disability. It appeared that the patient did not meet the VA requirements for the Caregiver Support Program as tendered in the denial assessment dated XXXXX which was reviewed.

This reviewer was unable to determine a Tier level Rating based on the information provided.

REFERENCES, IF APPLICABLE:

Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM V)

REVIEWER’S CREDENTIAL & SPECIALTY:

XXXXX

All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review.