(cell phone 240-506-1556)

To: All veterans

Date: 2015

From:

Topic: Primary Care and Spine

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)

for Veteran benefits

Craig N. Bash, M.D.

Neuro-Radiologist
www.veteransmedadvisor.com

Pages: 2
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

Primary Care and Spine

Most veterans have some sort of back injury due to the strains of service. Thus is common in
clinical practice as about 80% of the neuro-imaging cases that I review involve spine
issues.
Unfortunately, many patients go to primary care physicians/providers (Family Practice and
Internal Medicine and nurse practitioners and physician assistants) for their spine issues.
I have recently noticed that primary care physicians have provided medical nexus
opinions for veteran patients for the VA, which I have subsequently had to review and edit
so that correct benefits can be approved. The issue of expertise involves years of
training known as postgraduate years (PGYs) and I have 7 PGY years whereas the
average primary care physician has only 3 PGY years and NPs/PAs have even less.
It should be noted that Spine cases are difficult to understand due to their complexity and a
recent New England Journal of Medicine -NEJM (March 26, 2015 page 1247) article touched on
this issue by stating the following:
. MRI should be ordered by clinicians who can interpret the results; it is discouraged
at the primary care level.
The NEJM recognizes the limitations of primary care physicians and thus in these complex
spine cases the VA deciders should defer to the spine experts and the neuro-imaging.

It is not uncommon for soldier patients to also have life long complications from spine issues
with both bowel and bladder dysfunction.
Occasionally, some patients have complications that limit their ability to walk and are thus often
house bound. The VA has special ratings for these situations and they are contained in
the Special monthly Compensation rules (SMC). The rules are very complex. I have
been working with them for 20 years but I was told by a long term VA appeals executive
(BVA-AMC level) that only a handful of VA employees comp0letely understand the
complex SMC rules.
***Many of these SMC codes are rated significantly above the 100% level because they involve
multiple organ system simultaneously and it is the interdependence of the multiple systems that
makes these codes complex and difficult for the physician and rater alike to accurately
determine the level of illness.
Recommendations:
1. All soldiers should seek experts, which are acceptable to the VA and have proven track record
as armature VA IME/IMO physicians can complicate the claims process, which of course can be
detrimental to the outcome as each word is important in the opinion.
2. In the spine area a physician with neurologic training is an absolute requirement as noted in the
NEJM article above.
3. All soldiers should be aware of secondary complications from spine inquires and the need for an
analysis of SMC codes.
4. All claims should be placed on the correct forms as VA has adopted a draconian rule in 2015 of
No form No benefits
Craig N. Bash M.D.
Associate Professor
drbash@doctor.com
cell 240-506-1556
Independent Veteran Medical Opinion (IMO)
Veteran Medical Nexus Opinion based on Veterans medical records for veteran benefits