DISCLAIMER: This story is fictional and created for educational purposes only. The characters and situations depicted are not real. This narrative serves as an educational resource to help veterans understand the VA claims process for orthopedic conditions and appeals. This content is not legal advice.
The Painful Reality of Underrated Claims
James Wilson glanced at the calendar on his North Seattle apartment wall. Six months since the VA’s decision that drastically underrated his conditions. Six months of climbing the stairs to his third-floor unit with a throbbing back and knee, each step a reminder of that convoy in Afghanistan twelve years ago.
His phone buzzed with a text from his teenage son: “Still coming to my game tomorrow?”
James typed “Of course,” even as he wondered how long he could sit on those hard bleachers before the pain became unbearable. Twenty percent. That’s what the Seattle Regional Office had decided his injuries were worth, despite the fact he couldn’t stand for more than thirty minutes or sit for more than an hour without severe pain.
It had been a long journey already. Three years after separating from the Army in 2017, James had finally filed his initial claim on his own with the Seattle Regional Office. He’d waited until the pain became unbearable, until he’d missed too many days at his security consulting job, until his ex-wife had commented on how he winced every time he tried to play basketball with their son.
How C&P Exam Mistakes Impact Orthopedic Ratings
The C&P exam for that initial claim remained vivid in his memory. He’d arrived at the VA Puget Sound Healthcare System twenty minutes early, determined to get the benefits he deserved. But when the examiner asked about his pain levels, James had defaulted to the same stoic responses he’d given his commanding officers in Afghanistan.
“Pain level? I’d say a 4 out of 10 on average,” he’d told the examiner, not mentioning that it regularly spiked to 8 or 9 after climbing stairs or standing through his son’s basketball games.
The examiner had moved his leg and asked, “Tell me when it hurts.”
James had gritted his teeth and let the doctor push his knee and bend his back far beyond what would be comfortable in daily life. He’d been determined to “tough it out” during the exam, not understanding that this approach was sabotaging his claim.
That first claim had resulted in a service connection for both his back and knee injuries – a small victory since the VA acknowledged these conditions were related to his military service thanks to his medical records from Madigan Army Medical Center. But the ratings were a disappointment: a combined 20% rating – just 10% for his knee and 10% for his back. Nowhere near what his daily pain warranted.
James had filed a Higher-Level Review eight months ago, hoping a senior rater would see what the first had missed. That resulted in the same decision, leaving him with few options and deepening his frustration with the Seattle VA system.
Finding the Right Guidance for VA Appeals
The next morning, while waiting for his bus in the persistent Seattle drizzle, James noticed an older veteran with a Vietnam-era jacket waiting at the same stop.
“Weather’s not doing my back any favors,” the man said conversationally. “You serve?”
“Army. MPs at JBLM, then two deployments,” James replied.
“Robert Garcia,” the man said, extending his hand. “Marine Corps, then thirty years with King County VSO office before I retired.”
“James Wilson. VSO?”
“Veterans Service Officer. We help navigate the claims maze,” Robert explained as they boarded the bus. “You got that look about you—the VA-claim-frustration look. I counseled thousands of vets with that same expression.”
James found himself explaining his situation—the low rating percentages, the Higher-Level Review denial, and his growing feeling that the system was designed to wear him down until he gave up.
Robert nodded knowingly. “The biggest mistake veterans make is seeing the VA as an opponent rather than a system. Systems don’t care if you’re frustrated. They just follow rules and regulations.”
“What do you mean? I’m not tracking...” James asked.
“It means you need to understand how C&P examiners and raters evaluate orthopedic claims,” Robert said. “They follow specific diagnostic codes with concrete criteria. For example, knee limitations are rated based on specific range of motion measurements—how far you can straighten or bend your knee.”
As the bus navigated Seattle’s hills, Robert explained how VA rating decisions weren’t arbitrary but based on standardized evaluations of functional limitations.
“So what’s my next move? Another appeal?” James asked.
“You need to meet with someone who specializes in orthopedic appeals,” Robert replied. “I know just the person. A VA Accredited Claims Agent who used to be an orthopedic specialist at the VA. She knows exactly how C&P exams should be conducted and what evidence moves the needle on these cases.”
Understanding VA Diagnostic Codes for Orthopedic Conditions
The following week, James met Robert at the King County Veterans Program office. Robert introduced him to Melanie Chen, a VA Accredited Claims Agent who specialized in orthopedic appeals.
“Tell me about your C&P exam,” Melanie said after reviewing James’s ratings decision.
James described the appointment, including how he’d pushed through the pain during range of motion tests.
Melanie sighed. “That’s exactly what I see with most veterans, especially those with combat experience. You’re trained to minimize pain and demonstrate strength. But in a C&P exam, that approach works against you.”
She pulled up a document on her tablet. “This is VA Form 21-0960M, the Disability Benefits Questionnaire for musculoskeletal conditions. See these sections about pain during range of motion and functional loss? The examiner is supposed to document the point where pain begins, not how far you can push through it.”
“My doctor never explained this,” James said, suddenly understanding why his initial claim had been underrated.
“Most don’t,” Melanie replied. “Now look at these diagnostic codes. For your knee, the VA uses Code 5260 for flexion and 5261 for extension. Each percentage has specific measurements. For a 30% knee rating under Code 5261, extension must be limited to 20 degrees.”
Melanie then outlined a strategic approach to filing a Supplemental Claim—the appropriate appeal path when introducing new and relevant evidence that wasn’t previously considered.
“Here’s what we need to do,” she explained. “First, you need a proper examination with someone who understands VA criteria. I’ll refer you to an orthopedic specialist who regularly works with veterans. Second, we need statements from people who witness your limitations—your ex-wife, your son, coworkers. Third, you need to document how your environment impacts your condition—those Seattle hills, the damp weather, the stairs to your apartment.”
Building the Right Evidence for a Supplemental Claim
Over the next month, James followed Melanie’s plan meticulously:
- He visited the orthopedic specialist she recommended, who conducted a thorough examination following the exact VA protocols
- During the exam, the doctor noted the precise point where pain began during each movement—not just the maximum range James could force himself to achieve
- The specialist measured his knee extension and documented that it was limited to 20 degrees by pain, exactly meeting the criteria for a 30% rating
- He collected statements from his ex-wife about how his condition affected activities with their son
- His supervisor provided documentation about workplace accommodations
- He kept a detailed journal showing how Seattle’s weather and terrain impacted his mobility
- He photographed the three flights of stairs to his apartment, documenting how they affected his daily function
“Your C&P examiner measured your maximum tolerance,” the orthopedic specialist explained during the exam. “But VA policy clearly states they’re supposed to consider the point where functional movement becomes painful. That’s the measurement that matters for your rating.”
The specialist provided a detailed medical opinion addressing each rating criterion specifically, connecting James’s limitations directly to his documented service injuries. The report included citations to relevant medical literature and VA policies about how orthopedic conditions should be evaluated.
With Melanie’s help, James filed his Supplemental Claim exactly nine months after his initial denial, well within the one-year window that preserved his original effective date. The form included the new medical evaluation, lay statements, and a written argument citing specific diagnostic codes and VA regulations.
Turning Strategic Knowledge into VA Claims Success
Three months later—and almost two years since his initial claim—James received notification that his Supplemental Claim had been successful. His knee rating increased to 30% under Diagnostic Code 5261 and his back to 40% under Code 5237, with an additional 10% for associated sciatic nerve involvement. The combined 60% rating would make a significant difference in his life.
Even better, because he had filed within one year of his initial decision, the increased benefits would be retroactive to his original filing date, providing a substantial backpay amount.
“The VA isn’t designed to be generous or stingy,” Melanie told him when they met to review his decision. “It’s designed to apply specific criteria to specific evidence. Once you understand that, you can work with the system instead of fighting against it.”
James reflected on his journey as he took the elevator—not the stairs—to his new first-floor apartment the following month. The strategic veteran doesn’t try to overcome the VA’s procedures—they leverage them. The solution isn’t sending more evidence, but sending the right evidence in the right language.
Here’s the revision with a stronger active voice and refined flow:
The VA Is a System—Your Strategy Must Align with It
The VA follows rules. It applies regulations. It doesn’t make decisions based on pain—it looks at evidence. Veterans who win don’t fight harder. They fight smarter. James didn’t just send more paperwork. He sent the right proof. The system isn’t personal. It runs on laws, criteria, and documentation.
So here’s the real question: Does your claim align with what the VA needs to approve it?
Know a veteran stuck in the process? Share this—it could be the breakthrough they need.