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Thursday, June 9, 2022

The Promise to Address Comprehensive Toxics Act (PACT Act)—The Facts

Almost a year ago, the Honoring our Promise to Address Comprehensive Toxics Act of 2021 (known as “Honoring our PACT Act of 2021”) was first introduced to the House of Representatives. The House passed the PACT Act with a strong majority in March of this year, and the Act was read into the Senate at the end of May. 


The purpose of the PACT Act is “to improve health care and benefits for veterans exposed to toxic substances, and for other purposes.” But what really does that mean? What are the “other purposes”? And what can we expect to see happen if the Senate passes the Act and the President signs it into law?


Well, the Honoring our PACT Act will make changes in 7 key areas. Below, I’ve discussed the facts of the 7 areas and provided my personal thoughts on each. The Senate can still propose amendments, so things may be adjusted between now and the final law. 


Title I:  Expansion of Health Care Eligibility. This Title grants: 

1.     Eligibility for mammography screenings for veterans who served in locations where burn pits were used. 

2.     An extended deadline for health care enrollment from 5 to 10 years for combat veterans. This includes a 1-year open enrollment period for those who missed their 10-year window. 

3.     Eligibility for full medical care, including nursing home care, for any illness for toxic-exposed veterans. To qualify, the veterans must have been discharged between August 2, 1990 and December 31, 2018, and either

a.     served in Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, Somalia, or the United Arab Emirates on or after August 2, 1990

b.     served in Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Syria, Yemen, Uzbekistan, or the Philippines on or after September 11, 2001

c.     deployed in support of a contingency operation (Operation Enduring Freedom, Operation Freedom’s Sentinel, Operation Iraqi Freedom, Operation New Dawn, Operation Inherent Resolve, and Resolute Support Mission); or

d.     participated in an activity that risked toxic exposure. The activity must have been officially recorded or be on a list that the VA is currently compiling.


Thoughts: This will give access to VA health care to many veterans who do not currently qualify, so great news all around. The only vague area that could be troublesome is the toxic exposure activity qualification. If a veteran has to have participated in an activity that was officially recorded or on a list, this could end up excluding many instances of exposure. Now, to give the VA and DoD credit, they are working to improve the exposure reporting system for current service members and to go back and record historic exposures of which they have evidence, but we already know that the DoD was notoriously awful at recording exposures, so the likelihood of them catching all instances is low. It’ll be interesting to see how comprehensive the list is that the VA is currently compiling. Regardless, this is great news for many veterans. 


Title II:  Toxic Exposure Presumption Process. This Title makes multiple changes that are focused on improving the toxic exposure presumption process. It will:

1.     Establish a Formal Advisory Committee on Toxic Exposure. This Committee will compile and review all available evidence regarding toxic exposures, including scientific research, known cases, news, veteran’s statistics, etc. Based on this review, the Committee will then:

a.     Identify new and emerging exposures

b.     Recommend formal studies of the health effects of certain exposures if it seems that these studies could change the current understanding of the health outcomes of such exposures

c.     Recommend ways to fix the exposure recording system 

d.     Recommend which previous veterans’ cases of toxic exposure should be re-reviewed

e.     Recommend how the Presumptive List should be adjusted based on the evidence

2.     Require the VA Secretary within 2 years to create a list that details likely exposures to substances, chemicals, and airborne hazards for veterans who served during specific times in various key locations. This list will be broader and more comprehensive than any current list.

3.     Require the VA Secretary to conduct official research based on the Committee’s recommendations. Based on the results of such research, the Secretary will then update the Presumptive Lists accordingly. If this results in the removal of a current presumptive illness, the veterans already awarded for that illness will continue receiving those benefits.

4.     Allow veterans whose toxic exposure claims have previously been denied to elect to re-open their claim. If awarded benefits under the new lists, they will be compensated back to the original effective date of their claim.


Thoughts:  Yes, this is an essential step to getting toxic-exposed veterans their deserved benefits. There is currently little official research regarding the health effects of various toxic exposures, so by performing this research, creating new lists, and re-opening claims, the likelihood is that thousands of veterans will finally start receiving their benefits. Great news all around.


Title III:  Improving the VA’s Service-Connection Process for Toxic Exposure. This Title will: 

1.     Require the VA to conduct exams specifically meant to determine if there is a likelihood that a veteran’s condition was caused by toxic exposure when the veteran does not have sufficient evidence to prove toxic exposure. 

2.     Establish that veterans will be presumed to have been exposed to substances, chemicals, and airborne hazards (burn pits) if they: 

a.     served in Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, Somalia, or the United Arab Emirates on or after August 2, 1990

b.     served in Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Syria, Yemen, Uzbekistan, or the Philippines on or after September 11, 2001


Thoughts:  Again, no complaints here. This will expand the number of veterans eligible for the Burn Pit Presumptive List, which is great. Requiring the VA to conduct exams for those veterans who do not have enough evidence is also a really good thing. Instead of just denying the claim, they must get a qualified medical opinion that could end up granting service-connection for the veteran if the physician feels that the condition is “at least as likely as not” caused by the exposure. 


Title IV:  Presumptions of Service-Connection. This Title will make the following changes to the current Presumptive Lists:

1.     For Radiation Exposure, veterans who participated in cleanup activities or nuclear responses in Palomares, Spain (between January 17, 1966 and March 31, 1967), Thule, Greenland (between January 21, 1968 and September 25, 1968), and Enewetak Atoll (between January 1, 1977 and December 31, 1980) will be added to the list.

2.     For Agent Orange Exposure, veterans who served in Thailand on a US or Royal Thai base (between January 9, 1962 and June 30, 1976), Laos (between December 1, 1965 and September 30, 1969), Cambodia at Mimot or Krek (between April 16, 1969 and April 30, 1969), Johnston Atoll (between January 1, 1972 and September 30, 1977), or Guam or American Samoa (between January 9, 1962 and July 31, 1980) will be added to the list. The end date for service in Vietnam will also be extended to May 7, 1975. Finally, two conditions will be added to the Agent Orange List:  hypertension and monoclonal gammopathy of undetermined significance.

3.     For Persian Gulf veterans, veterans who served in Afghanistan, Israel, Egypt, Turkey, Syria, or Jordan will be added to the list. The conditions will also no longer be required to manifest to a certain severity within a certain time frame. It will be “to any degree at any time.” The VA will also be required to have their medical examiners use a new Gulf War Illness DBQ to ensure that the veteran is properly examined to consider the effects of service in the Persian Gulf.

4.     For Burn Pit Exposure, 24 conditions will be added to the list, including asthma, chronic bronchitis, chronic obstructive pulmonary disease, constrictive or obliterative bronchiolitis, emphysema, granulomatous disease, interstitial lung disease, pleuritis, pulmonary fibrosis, sarcoidosis, chronic sinusitis, chronic rhinitis, glioblastoma, head cancer, neck cancer, respiratory cancer, gastrointestinal cancer, reproductive cancer, lymphoma cancer, lymphomatic cancer, kidney cancer, brain cancer, melanoma, and pancreatic cancer.


Thoughts:  These changes will allow thousands of veterans to have their conditions service-connected, so this is great. With all the research the earlier Titles will require, these types of changes will become more frequent in the future. 


Title VResearch Matters. This Title will:

1.     Implement measures to improve data collection between the VA and DoD by creating an interagency working group to facilitate collaboration in toxic exposure research.

2.     Commission studies and various types of data collection to understand health trends of Post 9/11 veterans, health trends of toxic exposure, health effects of the Manhattan Project, health effects of jet fuels, incidents of cancer among the veteran population, and to determine whether it is feasible to provide healthcare to the dependents of veterans. 


Thoughts:  There definitely needs to be more research and data sharing. No question. The issue is that besides creating this work group, there are no other clear instructions on how to make this happen. The VA and the DoD have been trying to implement new strategies to share data for years now, but it clearly is still not enough since they need to create another work group. I’m a bit sceptical on how effective this will be, but hopeful that the work group will at least be able to come up with some successful data-sharing techniques. With modern tech, it really shouldn’t be as hard as the VA and DoD seem to have made it.


Title VI:  Resources and Training for Toxic Exposure. This Title will:

1.     Require the VA to create a training program for all employees dealing with toxic exposure claims to ensure proper medical examinations and claims processing. This includes a toxic-exposure questionnaire for physicians.

2.     Require the VA to provide resources to veterans who have or may have been exposed to toxics.

3.     Require the DoD and VA to create guidelines to use in active duty training to educate service members of the risks and prevention of exposures.


Thoughts:  Definitely necessary if these changes are going to be implemented seamlessly into the system. Employees need to know what’s up and veterans deserve to know what they are entitled to.


Title VII:  Registries, Records, and Other Matters. This Title will:

1.     Create a registry for AFFF/PFAS exposure

2.     Create a health registry for service at Fort McClellan

3.     Update and fix errors in the Burn Pit Registry

4.     Update and fix errors in exposure records

5.     Allow Camp Lejeune toxic water veterans to file tort claims. Tort claims are filed against the Unites States for a negligent or wrongful act. 


Thoughts:  Any way that the VA can get organized and collect the data they need to properly compensate disabled veterans is a good thing. 



That’s it. If passed into law, the PACT Act of 2021 will definitely make amazing improvements within the VA and DoD for toxic-exposed veterans, allowing many to finally receive the benefits they deserve. 


As of June 8th, a few Senators proposed minor amendments so hopefully it’ll be passed quickly and head to the President’s desk.  

Monday, April 11, 2022

Comments Submitted to the VA on the Changes to the Ratings for the Respiratory System and the Ears, Nose, and Throat

The following are the comments we submitted on your behalf to the VA in regards to the proposed changes to the ratings of the Respiratory System and the Ears, Nose, and Throat

After the VA publishes their proposed changes, they always allow a period for comments. Thank you for submitting your comments to us so that we could submit them in a unified front to the VA. Hopefully, we will be able to effect change and make the rating system fairer for all veterans. 

Here are the comments we submitted for the Respiratory System and the Ears, Nose, and Throat:


We at would like to submit the following comments on behalf of our staff and veterans in response to the proposed changes to the ratings of the Respiratory System and Ears, Nose, and Throat.


Comment #1. 


The addition of the 100% rating for peripheral vestibular disorders, code 6204, will be a huge benefit to veterans with very severe conditions. However, this leaves a large hole between the 30% and 100% rating. With the acknowledgement of a wide-range of symptoms and severities, it seems like these rating options will under-rate many conditions that interfere with work/self-care more significantly than the 30% rating requires but not completely, like the 100% requires. 


Additional rating levels would greatly benefit veterans who may require occasional assistance with tasks, but who can accomplish tasks themselves with modifications/accommodations other times. Perhaps a more tiered rating system that allows for task-interference a percentage of the time (ex. requires modification and/or accommodation 50% of the time, requires assistance of others 25% of the time, etc.), like the recently proposed changes to the mental disorder ratings, would allow for ratings that more accurately reflect the impact of the condition on work and daily life.


Comment #2. 


For the proposed General Rating Formula for Respiratory Conditions, the 100% ratings for acute respiratory failure and outpatient oxygen therapy are not included. However, in §4.96 paragraph C, the notes regarding not requiring PFTs when there is acute respiratory failure or outpatient oxygen therapy remain. These notes imply that these conditions can be rated without the need for PFTs, but the ratings for them have been removed. Without these tests performed, what is the intention for rating acute respiratory failure and the need for oxygen therapy? If the intent is for them to not be independently rated, then removing them from §4.96 (c) would ensure the PFTs needed to rate the conditions are performed. Otherwise, there is no system in place to correctly rate them.


Comment #3. 


The removal of an independent rating for tinnitus based on the assertion that tinnitus is a symptom only and not an independent condition is not fully supported by medical research. There are a number of studies that acknowledge the presence of tinnitus in the absence of hearing loss or other identifiable underlying conditions, and a 2017 publication summarized that “the majority of tinnitus patients are affected by chronic idiopathic tinnitus.” 


In order to ensure that veterans are properly compensated for tinnitus in cases without a ratable underlying cause, we ask the VA to consider retaining an independent tinnitus code, but possibly adding instruction that limits the application of the code when an underlying condition (like Meniere’s or hearing loss) is identified and rated.


Friday, March 11, 2022

Comments Submitted to the VA on the Changes to the Ratings for the Digestive System

The following are the comments we submitted on your behalf to the VA in regards to thproposed changes to the ratings of the Digestive System. After the VA publishes their proposed changes, they always allow a period for comments. Thank you for submitting your comments to us so that we could submit them in a unified front to the VA. Hopefully, we will be able to effect change and make the rating system more fair for all veterans. 

Here are the comments we submitted for the Digestive System:


We at would like to submit the following comments on behalf of our staff and veterans in response to the proposed changes to the ratings of the Digestive System.


Comment #1. 


For code 7203, Esophagus, stricture of, the definition of “refractory” requires at least 5 dilation treatments at 2-week intervals. With the rating requirements, the minimum rating this would qualify for would be 50%, since that requires 3 or more dilation treatments/year. Yet, refractory strictures are included on the 30% rating, though by definition they cannot qualify. Please adjust the requirements to clarify exactly how many dilation treatments are required for the various rating levels and for the condition to be considered refractory.


Comment #2.


The rationale for rating both GERD (code 7206) and Hiatal Hernia (code 7346) under code 7203 states that “these criteria consider symptoms of esophageal obstruction and irritation.” This is not the case, however. The wording of code 7203 only includes dysphagia as a ratable symptom. The 0% and 10% ratings both require no other symptoms and the 30% rating requires dilation. Under the current rating requirements these conditions could both easily qualify for a 30% based on heartburn, reflux, pain, etc., but there is no clear way to rate these symptoms on the proposed requirements for 7203. Both of these conditions, therefore, will have no way to be properly rated on the symptoms they cause. Please consider adjusting the rating options so that these symptoms can continue to contribute to the ratings for these conditions.


Comment #3.


For code 7329, the proposed ratings for 60% and 100% are inconsistent. The 60% rating simply states a “total colectomy without high-output syndrome.” A logical 100% rating would then simply be a total colectomy with high-output syndrome. Instead, additional requirements are included in order to achieve the 100% rating (ileostomy, 3 or more episodes of dehydration, etc.). 


Because of the significant jump between rating requirements, inconsistent ratings are likely to be applied in cases that fall between these two requirements. For instant, a total colectomy with high-output syndrome, but no ileostomy. 


We request that the VA clarify the rating requirements to ensure appropriate ratings between the 60% and 100% levels, with the potential to add an intermediary 80% rating to cover the cases that fall between. 


Comment #4.


Under the 60%, 30%, and 10% ratings for code 7332, the incontinence requires “wearing” a pad a specific number of times each week or month. 


The “wearing” requirement for the pads is a bit difficult to distinguish unless the incontinence episodes are 100% predictable. If there are two episodes/week, the patient would likely wear pads every day since they wouldn’t be able to predict when the episodes would occur. 


The 100% rating uses “changing” as the pad requirement instead of just “wearing.” A similar wording of the 60% and 30% would then allow pads to be worn regularly, just in case, but only the need to change them after an episodewould qualify for the rating. 


Comment #5. 


Dietary modification is used as rating criteria under a number of codes, but the phrasing is inconsistent. “Prescribed dietary modification,” “dietary intervention,” “dietary restriction,” etc. In order to clarify and ensure consistent application, we request that the terms are either standardized throughout if all mean the same thing, or clearly defined if there are differences. 


Similarly, though numerous important terms are clearly defined in 4.112, these terms are not consistently used throughout the proposed ratings. For example, under code 7355, “weight loss resulting in wasting and nutritional deficiencies” does not clearly specify weight loss as defined in 4.112. Similarly, the term “malabsorption syndrome” is used in this code, but not defined in the rating schedule. It ultimately results in undernutrition, so “undernutrition” could be used in place of it since the defining symptoms support the accompanying ratings. Again, consistency in terminology throughout will greatly help reduce confusion and aid consistent application. 


Comment #6.


For code 7347, a 60% rating requires hospitalization for complications of pain or enteral feeding. Enteral feeding is not included in any of the other rating options for this code. Under other proposed codes, enteral feeding is rated 80% with no caveats for number of hospitalizations or complications. Further clarification is needed on how to rate this condition if it requires enteral feeding, regardless of whether or not that feeding causes complications. Please also consider applying the 80% rating for enteral feeding in order for it to align with the rest of the proposed ratings.


Comment #7.


Under code 7356, the wording for the 50% rating is unclear. 


“With recurrent emergency treatment for episodes of intestinal obstruction or regurgitation due to poor gastric emptying, abdominal pain, recurrent nausea, or recurrent vomiting.” 


Is the emergency treatment only for the intestinal obstruction or also for the regurgitation? Is the obstruction also “due to poor gastric emptying, abdominal pain, recurrent nausea, or recurrent vomiting” or is that only for the regurgitation? Adjusted wording for further clarification would be appreciated. 


Similarly, the 30% rating requires symptoms of CIPO and intestinal motility disorder, but CIPO is an intestinal motility disorder, so this is repetitive and misleading, implying that these conditions are separate and distinct with different symptoms. Please clarify for clarity and correct application.


Thanks for considering our comments on the proposed changes to the ratings of the Digestive System.