(cell phone 240-506-1556)

To: All veterans

Date: 2015

From:

Topic: TBI-- Grant if You Can.

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)

for Veteran benefits

Craig N. Bash, M.D.

Neuro-Radiologist
www.veteransmedadvisor.com

Veterans TBI association (VTBI)

Pages: 4

NPI or UPIN-1225123318- lic #--D43471

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

The VA has a historical Culture of the following: Grant if You Can -Deny if you
must

Which is in line with the benefit of the doubt rules but recently the confusion around the TBIPsychiatric co-morbid diseases has moved the VA toward grants for TBI associated
PTSD and statements that other TBI symptoms cannot be determined without mere
speculation. This situation occurred lividly in the recent facetime virally documented case
of Eric Hunter- also highlighted on ABC 7 news on 12 June 2015. This patient was in an
IED blast and lost his right leg and had 6 fractures of his remaining left lower leg and he
needed over 60 surgeries to repair all of the IEDs blast damage to multiple regions of his
body. The uniformed surgeons at Walter Reed and in the war zone preformed over 40
surgeries just to salvage his left leg.
The Gulf war signature injury is TBI and the numbers of injuries is large (likely 300,000+) as I
mentioned in my previous bulletin but it is becoming clear that the VA is having a hard
time providing an accurate ratings for this concoction because is involves many complex
areas of the rating code.
For example, many patients are receiving a diagnosis and rating for single psychological issue
( Eric Hunter s case) when in fact they really have over lapping issues that stem from an
undiagnosed TBI. Many of these patients present with decreased cognition, headaches,
vertigo, memory loss most of which has never been linked to a TBI. Many of the TBI s
are in the mild to moderate category (80%) and these are not identified on routine MRI
brain imaging because the MRI findings are subtle and not seen with the human eve.
A new techniques called Neuroquant ( a single add on 10 minute MRI sequence that is
compatible with 90% of MRI scanners) uses a computer analysis to assess the loss of
whole brain volume and regional volumes to help better define patients Pathology in
patient who have mild to moderate TBI symptoms. The abstract of a recent paper
describing this process is below:
Neuropsychiatry Volume 25, Issue 1, Winter 2013

Man Versus Machine: Comparison of Radiologists Interpretations

and NeuroQuant Volumetric Analyses of Brain MRIs in Patients
With Traumatic Brain Injury
David E. Ross, , M.D.Alfred L. Ochs, , Ph.D.Jan M. Seabaugh, , M.A.Carole R. Shrader, , B.A.the Alzheimer's
Disease Neuroimaging Initiative
View Author and Article Information
Received: December 30, 2011
Accepted: May 26, 2012

http://dx.doi.org/10.1176/appi.neuropsych.11120377

Abstract

NeuroQuant is a recently developed, FDA-approved software program for measuring brain MRI volume in
clinical settings. The purpose of this study was to compare NeuroQuant with the radiologists traditional
approach, based on visual inspection, in 20 outpatients with mild or moderate traumatic brain injury (TBI). Each
MRI was analyzed with NeuroQuant, and the resulting volumetric analyses were compared with the attending
radiologists interpretation. The radiologists traditional approach found atrophy in 10.0% of patients;
NeuroQuant found atrophy in 50.0% of patients. NeuroQuant was more sensitive for detecting brain atrophy
than the traditional radiologists approach.

Once the TBI has been established then the VA codes allow for three different non pyramiding
categories of codes as follows;
1. Psychiatric/Emotional disabilities
2. Physical disabilities
3. Cognition-based on the table below:

Memory, attention, concentration, executive functions

Judgment

Social interaction

Orientation

Motor activity (with intact motor and sensory system)

Visual spatial orientation

Subjective symptoms

The three areas of codes involved complicated Brian interconnections and thus this is hard for
the routine VA rater to grasp and understand the level of dysfunction and accomplish a correct
rating in his 2 hour allocated time window for rating of TBI. Due to the complexity of these
issues and the interconnected potential TBI ratings most TBI patients are in-correctly rated.

Recommendations:
1. All patients service time medical symptoms should be assigned an diagnosis and treatment plan
by a military physician prior to discharge.
2. All patients exposed to any type of blast should file for TBI as loss of consciousness is not
required for significant TBI to occur. Especially if they have residual balance, vertigo, memory or
chronic headaches following the blast.
3. All patients with blast history should be screened by a physician and based on the physicians
screening evaluation a large sub-set of post-blast injured patients should likely be scanned
using the MRI based 10 minute Neuroquant sequence. Neuroquant provides an analysis of the
brain volumes and this should be done for baseline analysis and treatment follow-up.
4. All patients should get a medical nexus opinion concerning their blast injuries if the above
testing is positive. This evaluation should be provided to a Physician-rater team of C-P
examiners.
5. All veterans should get a VA CP exam done with simultaneous interviews with both a physician
and a senior VA rater (team of CP evaluators) so that none of the salient medical or ratings
issues is overlooked. I recently BETA tested this approach and found that is it the most efficient
effective and accurate way to provide a patient with the correct medical diagnoses- which are
linked to their appropriate VA diagnostic codes. I was able to do CP exam in the morning with
the rater and in the afternoon do the IME while the rater did the rating. We found that in an 8
hour period of work we did 4 patient CP exams, 4 patient IMEs and 4 patient ratings.
6. This approach, if adopted system wide by the VA would decrease the number of appeals and
wrong codes. A single wrong code occurred in the case with Eric Hunters claim (28 ratings). In
Erics case, the physician simple lumped together his left knee and lower leg into one rate
category, which in the end put him at 90%. When the knee and lower leg were rated separately

then his rate become 100% on 11 June 2015 but his TBI manifestations were still under appeal
as of 12 June 2015.
.
*** Please remember that the VA now (March 2015) has a new policy of No Form No Benefit
(NFNB) so please do the forms as carefully as possible.
Craig Bash M.D. Associate Professor
drbash@doctor.com cell 240-506-1556
Independent Veteran Medical Opinion (IMO)
Veterans TBI Association
Veteran Medical Nexus Opinion based on Veterans medical records for veteran benefits