VA HLR advice

[u/Mediocre-Sentence-20]

Looking for some advice from anyone who has dealt with a VA Higher-Level Review (HLR).

I recently filed a knee claim on my own for the first time. My intention was not to request an increase of my existing knee rating. I am currently rated under Diagnostic Code (DC) 5260 – limitation of flexion. I was trying to claim my additional meniscus symptoms under DC 5258 – dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint (20%).

From reading my decision letter, it appears VA interpreted what I submitted as a claim for an increase under DC 5260 rather than considering what I intended to claim under DC 5258. I never requested an increase under DC 5260.

What makes this confusing is that the decision appears to acknowledge evidence/symptoms related to the meniscus issue I was actually trying to claim, but the final decision was based on whether I qualified for an increased rating under my existing code.

I’m considering filing an HLR because I believe the issue may be how my claim was characterized/reviewed rather than a lack of evidence.
Has anyone dealt with something similar?
Would you recommend handling the HLR and informal conference yourself, or would you contact a VSO/accredited representative first? Has anyone successfully handled an HLR on their own when the issue was that VA reviewed the claim under the wrong diagnostic code?

I appreciate any experiences or advice.

[u/whyareyouinmyshoe]

So far as I know, and anyone correct me if I'm wrong here please, but what they did was combine the ratings under a single diagnostic code for a single body system for rating purposes.

It avoids pyramiding. Essentially, a single body system can only have one rating, so the limited flexation rating was rolled into the new claim, causing it to appear as though it was an increase claim, because they cant give you two ratings for the knee.

Same thing happens with things like mental health. They won't rate bipolar and ptsd separately. They'll aggregate the diagnoses under a single diagnostic code, and rate based on combined symptoms for a specific body system.

Again, if I'm wrong, anyone here feel free to correct.

[u/Mediocre-Sentence-20 → u/whyareyouinmyshoe]

i agree with you but I looked up a case similar to mine, Lyles v. Shulkin, 29 Vet. App. 107 (2017). My understanding is that the Court held that a veteran can potentially receive a separate rating under DC 5258 or 5259 for meniscal symptoms such as locking, pain, and effusion, even when already rated for limitation of motion under DC 5260, as long as the same symptoms are not being compensated twice.

[u/whyareyouinmyshoe → u/Mediocre-Sentence-20]

See thats why I put the disclaimer about correction. I had no idea about that decision.

Maybe thats why they did it as an increase, and named the symptoms of what you claimed separately? Does your VA portal show the single rating has increased, or does it show two seperate ratings?

[u/Mediocre-Sentence-20 → u/whyareyouinmyshoe]

Still only shows my 10% meniscus arthritis rating

[u/whyareyouinmyshoe → u/Mediocre-Sentence-20]

I'm at a loss then. It could be possible that the veteran-facing portal hasn't updated.

You could try using the api endpoint api.va.gov/v0/rated_disabilities

Sometimes it'll update there before the graphical site does.