Documenting and Rating Spondyloarthropathies
Documenting and rating Spondyloarthropathies is often not understood very well by MEB, PEB and VA officials. Proper documentation in MEBs and TDRL review examinations is critical. Per DoDI 1332.38, MEBs and TDRL review examinations physicals are required to cover all medical conditions with full clinical data. In addition, the 14 October 2008 DoD Directive Type Memorandum requires that MEBs include the minimum data from applicable VA AMIE worksheets. These worksheets can be found here:
http://www.vba.va.gov/bln/21/Benefits/exams/index.htm
Spondyloarthropathy, depending on manifestations, can include the need for the data from the following VA worksheets, depending on manifestations:
Bones:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm06.pdf
Eyes:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm20.pdf
General Medical Exam:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm23.pdf
Hand, Thumb, Fingers:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm27.pdf
Heart:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm28.pdf
Infectious, Immune and Nutritional:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm28.pdf
Intestines:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm33.pdf
Joints:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm34.pdf
Respiratory:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm48.pdf
http://www.vba.va.gov/bln/21/Benefits/exams/disexm49.pdf
Skin Diseases:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm52.pdf
Spine:
http://www.vba.va.gov/bln/21/Benefits/exams/disexm53a.pdf
To ensure proper ratings, it is critical that MEBs, TDRL review physicals and VA C&P examinations properly cover all the manifestations of Spondyloarthropathy.
Spondyloarthropathy is rated under DC 5002 and is complicated. Ankylosing Spondylitis is even more complicated due to the addition of VASRD 5240 (Ankylosing Spondylitis) in 2003. When DC 5240 was added, many VA and military raters opined that DC 5002 rating criteria could no longer be used for Ankylosing Spondylitis. This was never true but it still took me over four years to get the VA to clarify this issue and many wounded warriors were cheated out of proper benefits in the interim. In the February 2009 VA Conference Call newsletter, the VA stated the following:
Evaluating claims for ankylosing spondylitis
Ankylosing Spondylitis (AS) was assigned a specific Diagnostic Code (DC) of5240 with the VA Schedule for Rating Disabilities change for conditions of the spine in September 2003. C&P Service has received multiple inquiries from veterans’ advocates, indicating that AS is being improperly evaluated in light of this change. DC 5240 falls under the General Rating Formula for Diseases and Injuries of the Spine. Raters must be cognizantthat AS, in addition to causing limitation of motion of the spine or other symptoms, may be an active disease process. If the AS is manifested as an active disease process, consideration must be given to evaluating it under the provisions of DC 5009, as an arthritic process. DC 5009, according to the schedule, is to be evaluated under the criteria for rheumatoid arthritis, DC 5002. AS, when an active process, may affect other joints or body systems. Such other residuals should be identified and properly adjudicated.
Therefore, when evaluating AS, the RVSR must determine, based on the evidence in file, if the AS is an active process, and if so, properly evaluate it under DC 5009 (5002). If the AS is quiescent, it would be evaluated under 5240 based on the chronic residuals affecting the spine as well as any other joints or body systems under the appropriate diagnostic code.
In August 2009, the United States Army Physical Disability Agency (USAPDA) released policy that echoes the VA clarification above. The policy can be found here:
https://www.hrc.army.mil/site/active/tagd/pda/AS.pdf. Other services should be rating Ankylosing Spondylitis in this manner.
The DC 5002 rating criteria has two parts, the active disease process and the chronic residuals. The active disease criteria still suffers from subjective rating terminology such as exacerbations, incapacitating exacerbations, severely incapacitating exacerbations, totally incapacitating, definite impairment to health and severe impairment to health. I have tried numerous times to get the VA to define these terms objectively but without success.
5002 Arthritis rheumatoid (atrophic) as an active process
With constitutional manifestations associated with active joint involvement, totally incapacitating 100%
Less than criteria for 100% but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods............................................................................ 60%
Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year …………..40%
One or two exacerbations a year in a well-established diagnosis............... 20%
It behooves individuals with Spondyloarthropathy to try and ensure their MEB, TDRL, review or VA exam describe their condition using this terminology. If the disease is in the active process (active inflammation treated with TNF drugs such as Enbrel or Humira) the report needs to state the disease is in an active process and use DC 5002 terminology to describe the impact.
VASRD DC 5002 also has criteria for chronic residuals. (Note: the higher of the active process and chronic residual criteria is used for the final rating). This chronic residual criteria is as follows:
For chronic residuals:
For residuals such as limitation of motion or ankylosis, favorable or unfavorable, rate under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.
Note: The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. Assign the higher evaluation.
Please note the 10% per joint provision as this can often lead to the highest rating. Every joint affected needs to be thoroughly evaluated to include a range of motion study. Each major joint (or set of minor joints) with any limitation of motion should be rated at no less than 10% disabling. If the spine is affected, and it usually is with Ankylosing Spondylitis, the residual damage to the spine in rated per VASRD DC 5240. Other joints affected are rated per the VASRD DC covering that area or condition.
All other manifestations of Spondyloarthropathy need to be included as well. This can include eye, lung, GI and heart issues. Often psoriasis is a manifestation of Spondyloarthropathy. If so, under VASRD DC 7816, it should be rated at no less than 60% disabling if it is treated on a continual basis with an immunosuppressive drug such Enbrel, Humira or Remicade.
In conclusion, Spondyloarthropathy is a tricky disease to evaluating and rate. It is important that those undergoing DES or VA evaluation for Spondyloarthropathy understand how these conditions are properly evaluated and rated and ensure their evaluations document the truth well.
A good place to read up on rating issues and proper rating procedures is the VA’s Board of Veteran Appeals (BVA). The BVA site is located here:
http://www.index.va.gov/search/va/bva.html
On the site you can search for Spondyloarthropathy cases and review the evaluation and rating issues raised on how the BVA ruled on these issues. Similarly, the US Court of Appeals for Veteran Claims (CAVC) website can be used to research Spondyloarthropathy cases and how the CAVC ruled on these cases. The CAVC website can be found here:
http://www.uscourts.cavc.gov/research_court_cases/DecisionsOpinions.cfm
Michael A. Parker
LTC, USA (Retired)
Wounded Warrior Advocate
