NARSUM from PCM vs 21-0819

tdyslider

PEB Forum Regular Member
Registered Member
Hello,

Got a copy of my NARSUM that my PCM wrote that went to the IRLO which came back for full MEB. But I had the initial meeting with the VA MSC today and both he and the PEBLO said that the even though the original NARSUM had 4 unfitting conditions, they would only put 1 condition on the VA form 21-0819 as unfitting and the rest on the 2nd page as only VA ratable not DOD ratable.

Is this correct? My PCM is awesome and wrote the NARSUM accurately and well, but I understand that there is another NARSUM later after the C&P exams? So even with that, how can they say now there is only one unfitting condition when I have the first NARSUM saying there are 4?

And what is the best way to fight this with the best supporting regs? And best time to try?

Thanks for the help

Oh and I am (was at least) and AF pilot - primary condition is diabetes, but the other unfitting conditions on the PCMs NARSUM were Knee, Back injuries, and hearing loss.
 
Its a little bit of a pet peeve of mine, but I do actually believe it is important. The only group that is able to determine unfitness is the PEB. None of your conditions are yet unfit. Your conditions are below retention standards. I know it sounds like the same thing, but its one of those instances where a simply turn of a phrase carries a lot of weight, in my mind anyway.

I am awful curious what causes them to believe you can only have one condition can be unfitting. All conditions have to be considered for being unfit or not. Almost any condition is capable of forcing you below retention standards. However, I do not believe the PEB ever views VA form 21-0819, as it is a form used to start a VA claim and has no real bearing on the MEB. Its the NARSUM (your PCM wrote up a draft, the MEB will have an official one for you to sign later) that lists what conditions are below retention standards and is important for the unfitting determination. I will note that my VA form 21-0819 had two conditions pre filled out as the cause for referral to IDES, they then gave the form to me to fill out my remaining conditions I wanted to claim.

DoD Instruction 1332.18, particularly appendix 1 to enclosure 3, 2nd paragraph covers what medical conditions cause a referral to the MEB (below retention standards). There is no restriction anywhere that says only a single condition can be below retention standards.
 
Thanks so much for the info-greatly appreciated.

So who got to determine from my PCMs NARSUM what got put on the 21-0819? And then who will determine what makes the final NARSUM?

Should I be worried about the 21-0819 at this point or just wait to see what's on the final NARSUM? And I'm assuming if I have issue with that based on the reg you cited I appeal at that time.

Thanks again for all the help - this is mind numbing.
 
It should have been filled out based on what your PCM wrote.

The section is titled -
MEDICAL CONDITIONS TO BE CONSIDERED AS THE BASIS OF FITNESS FOR DUTY DETERMINATION (List only conditions referred by physician):
So either a) you're confused about what the physician wrote or b) they're confused about how to fill out the form. That section should be pre-filled out based on your profile. There is no requirement that only one condition be a referring condition, nor does the VA require only one condition be rated for unfitness. The only way the conversation would make sense is if they said "Diabetes has to be listed there, that's all you were referred for". They seem to be saying you have to pick from the four conditions which one you want to be unfit. That's non-sense. You don't get to decide what disabilities you have and how severe they are, nor do you get to decide what the military finds acceptable. You just have to make sure the correct evidence is available so that they can make the right determinations.

Really, all that matters AFAIK is that between that section and the additional section every condition you have is listed. That will ensure a C&P exam is conducted and ratings are determined for everything, its not up to the VA to decide what's unfit anywho.

The final NARSUM is the result of the MEB. The MEB is a paper board, where a physician/physicians look over your records and document the what, why and the how of conditions failing retention standards. If it comes back FUBAR you can request an IMR for a second look at the NARSUM for accuracy. In addition and/or alternatively you can submit a rebuttal which is basically a memo detailing what is wrong with the NARSUM and why so that the PEB can make the correct unfit determination.
 
I guess I'll wait to see what the final NARSUM says since they did eventually get everything on that 21-0819, just all but one thing on the back.

Thanks again for all the great help and advice - it is greatly appreciated.
 
So I just got the final NARSUM, MEB results and C&P results back. There are some inconsistencies in the C&P results, but I think overall relatively minor ones. The NARSUM was just like the draft I saw and I think it is fairly good.

So here's the urgent questions I need to figure out before signing:

1) My diabetes is super rare and my specialists think that since it's not auto immune (the super rare part) that it's due to some exposure. (They've done every possible test proving that it's not autoimmune, but as I tried to get by for so long before going to the doc, there's no way now to ever determine exactly what damaged my pancreas, only that something did) I have been deployed with burn pits, but not when diagnosed, but the wounded warrior folks cited this for enrolling me in the program as "combat relation couldn't be ruled out". I also have radar exposure, and they stumbled on a nodule in my lung during all the exams, likely from the burn pits. So my NARSUM and C&P don't mention anything about the a possible combat relation that the wounded warrior folks saw, should I write an exception letter to the board to highlight this? Still waiting for determination on wounded warrior designation.

I also have a back injury from SERE (POW) training, which is documented and I think would fit the "under conditions simulating war" perfectly - but that's not likely unfitting by itself but if I do write a letter I was going to point that out as well.

2) My NARSUM lists 4 potentially unfitting conditions, but the 618 only has the primary as diabetes. The other condition I think should be on there is a well documented knee injury. The problem was, I never missed a PT test and always sucked it up and did well. I could barely walk each time I did that for months afterwards, but I always pushed through and didn't miss anything (which is accurately documented in the NARSUM) - Is there any case to get that considered for unfitting with either the IMR and or letter?

3) They wrote an addendum to the NARSUM adding the fact that I'm now on an insulin pump, and a line that says "all other not unfitting at this time" - Does that mean the other three "potentially unfiitting" things on the NARSUM won't really be considered as such by the PEB?

4) Does the PEB (and ultimately the VA) determine ratings off the NARSUM verbiage or the C&P results? There are some subtle but very important differences in the wordings of each. There are also a few errors in the C&P, but my PEBLO said I can only address issues with the NARSUM with the IMR or letter, so how would I fix errors on the C&P? Most are minor, but at this point I don't know what's really not a big deal and what isn't.

Thank you in advance for the help - I'm trying to go over everything again within the very short timeline that I have before I sign to figure out the best course from here.
 
I am awful curious what causes them to believe you can only have one condition can be unfitting. .
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I believe this clip from the MSD is the one condition that will be found unfitting.
 

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1) Writing a letter to get combat related issues for potentially unfit conditions is not a bad tactic.

You can appeal combat related problems you don't agree with for unfit conditions. You don't know what will be unfit, so for now, it potentially makes sense to send info about all conditions. Its not a bad thing to wait to see what they say and then disagree after you get the 199. If they find the back fit, combat related for that won't matter at this stage and the PEB won't say yes or no.

If combat related or not is a determination made by the PEB that will effect you in any significant way is another question entirely. It does not always present a significant issue. I would be surprised if can't rule out the possibility is clear enough for the PEB to agree that it is combat related.

2) The PT test is a factor in determining if a condition makes you unfit, but in reality, your job isn't doing a PT test every 6 months. If you can present evidence that the condition prevents accomplishment of your duties, that's what they need to determine unfit. Your story presented sounds like your knee sucks, which is fine for VA compensation, but not enough to say you need to be kicked out because of your knee. You'll want to get specific into how you can't do things, i.e. your job requires you to work pedals in the jet, which you just can't do anymore. Similar for the back, i.e. you can't sit in the seat for a flight. /shrug

3) Pretty much. The medical people don't think there's any reason for them to kick you out for the other 3 conditions. If you think they should, its a huge red flag with bright flashing lights that you should give them more evidence.

4) The PEB does not determine the rating in the IDES process.

The VA determines ratings, and they primarily utilize the C&P results. It is unusual for the NARSUM to speak about criteria important for determining a rating. Technically they utilize your entire medical records, but the C&P is an exam specifically for finding out all the info a rater needs and is heavily relied upon. You can submit additional evidence to the VA that they can consider as well. Generally by uploading to ebenefits, but the MSC should be able to send it up.

Its fairly easy to determine if information in the C&P will effect a rating by looking at the rating criteria in the VASRD. Its not always smart to haggle over minor wording use without understanding what is important. Example: C&P says you get 2 prostrating migraines a month, the NARSUM says you get 2 migraines a week. Instinct says 2+ migraines a week is worse and the NARSUM is better. Instinct is wrong. The fact the C&P used to word prostrating means you'd qualify for the max 50% rating, but the NARSUM is saying you'd get 0% rating because none of your very frequent migraines are serious enough.

Its important to note the different evidence and who needs what. PEB needs evidence showing you can't do your military job due to a condition. VA needs evidence showing how severe your condition is and how it interferes with social and occupational tasks.

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For the good Charlie: The point was the VA doesn't get to decide only 1 condition is unfitting.

It seems clear there is some level of confusion about what is actually preventing him from performing his job. Tdyslider seems to believe there are four conditions that are below retention standards. Its a bit confusing on what the profile / PCM actually said. The NARSUM seems fairly clear, the diabetes is severe enough to need you to be kicked out. It sounds like tdyslider believes his PCM said his knees, his back and some other condition was also severe enough to be kicked out. Its not clear why the PCM believes that or why the MEB disagreed. Its the why and the how of that disconnect that is pretty important to resolve at this stage.
 
Thank you both so much for the replies. I can't express how much help is appreciated right now.

I finally got an Lt at the OAC to call back today and she's going to review the draft letter of exception I wrote tomorrow. She feels strongly that I should request the IMR and submit the letter. And with what I got from you guys as well, it seems like it makes sense to do so, as long as I accidentally try to contradict wording in the C&P that might be more favorable.

Would you agree that at least that the IMR and letter likely won't hurt anything and best case it may help for down the road?

Of the 4 things the NARSUM originally had as potentially unfitting, the knee is the one that I think could stand on it's own. Problem is, while I have evidence that it was messed up on duty several times over the years, I went to great lengths to never miss anything because of it. Heck, even with the diabetes I about died before I went to a doc, and only then when my wife threatened to finish me off herself if I didn't go in. C&P and NARSUM sort of agree that my knee isn't good for running anymore, so I am probably just going to try the honest plain English approach and try to explain why I did well on every test anyway, and try to link in current impact if I were still flying. If the AF had told me to cut a kidney out with a dull spoon to stay flying, or even just stay in the military, I would have. So limping around for a couple months a year after running a mile and a half once a year seemed like a good idea at the time...

So I'm going to see what the Lt comes back with tomorrow, and while I hate to cause more work for anyone, it seems to me like while there may not be much upside at this point to getting the IMR and letter, there's also not much down side. Please let me know if you disagree.

Once again, thank you gentlemen so much for the inputs - hope to pay it back or at least forward someday.
 
So my OAC lawyer just said that because I am complete with the C&P, the VA is already in the process of making a ratings determination and I should get that in a couple of weeks in spite of the fact that my case hasn't been sent to the IPEB yet? So basically no matter what I put in a letter of exception, the ratings piece is already decided at this point and the first chance to contest will be the FPEB? Is this correct?

I just got the MEB results and have till Monday to decide on requesting an IMR or not - it has not been sent to the IPEB. And my PEBLO stated that the IPEB must first determine fitness/unfitness, then send it back to the VA to ask for ratings, and only then will they be determined. Which would seem that a letter of exception might actually matter a bit more in this is true.

Who is correct?!?
 
For my MEB it was very obvious that the VA started doing the ratings before the packet was sent to the IPEB. I believe your lawyer is correct.

The official work flow states that the VA starts the rating process after the IPEB. The work flow also says the VA gets less than a month to come back with a rating. One thing had to give, either the timeline or the process. The VA does not need anything from the NARSUM, MEB or PEB, so it makes sense they would ask for the ratings early to improve timelines.

Its important to understand there are two very separate questions being asked. What conditions are preventing you from continuing to serve and how severe are those conditions.

What conditions are preventing you from continuing to server - NARSUM, MEB, PEB, etc., works to answer that question. Everything that you don't agree with as far as that is concerned needs to be addressed through the military.

How severe are those conditions - The VA and C&P works to answer that question. Everything you don't agree with as far as that is concerned needs to be addressed through the VA.

After you get the results you can disagree with what is unfit at the FPEB. You can also disagree with the ratings and submit a VARR.
 
Thanks for the info, what you said makes sense although like you said that contradicts the literature about the process. The worst part about this whole process (other than the whole being sick thing...) is trying to figure out what the right info is.

You guys and this site are the best info out there. Thanks again
 
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