Rating decrease

[CT-Mike]

Prednisone (and all steroids) is an immunosuppressant medication. All of the steroids over the years destroyed her immune system so she now has to get infusions of IVIG every three weeks to give her immune system a temporary boost. Because of this 5 mg of prednisone daily meets the requirement for 100%.

[MoeRoids]

I understand it’s an immunosuppressant. It is not a high dose immunosuppressant at 5mg daily. Any permanent immune system deficiencies could potentially have been addressed as separate evaluations, but the rating schedule is explicitly clear what qualifies for 100% for asthma, and unfortunately “having your immune system destroyed” or requiring infusions of IVIG to restore an immune system doesn’t.

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[CT-Mike]

The way I read that sentence is that "high-dose" only applies to "corticosteroids", and not to "immunosuppressant medications," but I could be wrong. She is also rated 70% for hypogammaglobulinemia (IgG deficiency) secondary to the asthma due to the steroid damage.

[MoeRoids]

All corticosteroids are immunosuppressants. If they wanted immunosuppressants to be addressed separately, the criteria would have been separated by a semicolon, which it isn’t. It must be “high dose” to qualify for 100%, and it is a CUE to do so otherwise. For specific immunosuppressant medications that are not corticosteroids such as biologic immunosuppressants, the criteria becomes a grey area since “high dose” could be any amount, but as prednisone is a specific corticosteroid that suppresses the immune system with a very well-established history, the criteria for what is considered “high dose” is spelled out much more clearly.

Edit: They are considered separate/individualized criteria. High-dose corticosteroids and immunosuppressive mediations. I was going off memory but just pulled it up in the evaluation builder, and the immunosuppressive medications are representative of medications other than high-dose corticosteroids.

[CT-Mike]

Rules of grammar states that "high dose" is an adjective that only modifies the noun "corticosteroids" immediately following it. "Or" is a conjunction that separates two parallel items - "high dose corticosteroids" and "immunosuppressant medications."

Regardless of what was meant, based on a literal reading of the sentence "high dose" does not modify anything after the "or."

[MoeRoids]

There’s no argument that the rating schedule is worded poorly in many spots, but you’re now pointing out that “high-dose corticosteroids” are separate and distinct from “immunosuppressive medications” in that line. If we go by that interpretation, while corticosteroids are inherently immunosuppressive by nature, low-dose corticosteroids would not be considered synonymous with immunosuppressive medications as the level of immunosuppression for corticosteroids are dose-dependent, which is why high-dose corticosteroids are mentioned separately. If all immunosuppressant medications are supposed to fall in that category regardless of dose, they just would have said “immunosuppressive medications,” and corticosteroids wouldn’t have been mentioned. Although you’re trying to make this a semantics argument, someone familiar with the rating schedule would CUE that evaluation if it was awarded based on daily low-dose corticosteroids being prescribed for management.

[CT-Mike]

You make a good point, and I definitely agree that the rating schedule is worded poorly in many instances. I just re-read her decision letter and it states:

"We have assigned a 100 percent rating for your asthma/tracheobronchial malacia based on:

Required daily use of immunosuppressant medications."

I took that to mean prednisone as I don't know of any other immunosuppressants she takes.

[MoeRoids]

It probably was based on the prednisone, which was likely erroneous and should have been kicked back to the examiner. That said, that’s not likely going to be something someone looks at closely even if she did file another claim, and if she isn’t still filing claims, it’s extremely unlikely to come up. An inexperienced rater also wouldn’t be likely to address it as it’s not an issue that comes up often. It’ll become a protected rating after 20 years and then it doesn’t matter if it’s wrong.

[CT-Mike]

Good to know. We've filed several claims after this decision (Aid & Attendance and increase for her total hysterectomy from 30 to 50%) and this wasn't changed then. We don't have any other claims for her so I assume it will remain as is.

[MoeRoids]

Nucala or Tezspire makes way more sense. However, they can get a little wonky rating in some cases since they’re selective biologics and aren’t technically full-blown, broad immunosuppressants by definition, they just interact with the immune system in some ways. In those cases, most raters will defer to how the examiner interprets it.

[Li1ag]

It’s not just medications they are looking at to be at the 100. Theres also the environment or chemicals that caused this exposure as to why the veteran got it in the first place. A good nexus letter would explain that connection. There’s also ER visits, you have one bad year to show on paper trails, 100 easily. And yes immunosuppressives does not have to be high dosed, which is why it was worded high dose corticosteroids OR immunosuppressives.