THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: July 31, 2014 10:48 AM Thursday; Rod Welch

VA letter on regression atherosclerosis and need Podiatry referral.

1...Summary/Objective


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CONTACTS 

SUBJECTS
CBC Lab WBC VA No Results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2003 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2003 -    ..
2004 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
200501 - Follow up ref SDS 75 0000. ref SDS 74 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
200502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200509 -  ..
2006 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2007 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2008 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2009 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
200901 - On 131016 1632 submit letter for agenda meeting to review lab results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200902 - scheduled 131017 1000. ref SDS 40 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
200904 -  ..
200905 - On 140131 0815 ordered another lab - cbc, electrolytes, lipid with NMR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
200906 - - from Labcor to get LDL-P. ref SDS 50 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
200908 -  ..
200909 - On 140201 1159 had full lab with NMR lipid panel drawn at John Muir                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200910 - Hospital on Treat, and by Labcorp. ref SDS 51 RP4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
200912 -  ..
200913 - On 140203 1147 had partial lab drawn at VA in Martinez. ref SDS 52                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
200914 - KK9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200916 -  ..
200917 - On 140507 0857 ordered another full lab from Labcorp with NMR lipid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200918 - panel. ref SDS 58 OO5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
200920 -  ..
200921 - On 140508 1133 lab blood daw at Labcorp with John Muir Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200922 - on Treat Blvd in Concord. ref SDS 59 445G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200924 -  ..
200925 - On 140514 0950 VA partial lab at Medical Center in San Francisco.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
200926 - ref SDS 61 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200928 -  ..
200929 - On 140518 0920 letter to VA submits consolidated blood tests from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
200930 - Labcorp on 140508 and the VA on 140514, to prepare for the meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200931 - 140519. ref SDS 63 1V6M  Advise that VA has not ordered follow up lab                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
200932 - to check Electrolytes (Chem Profile) requested by Doctor Egan to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
200933 - assess previously elevated potassium (K) 5.6, that cause electrical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200934 - problems for the heart. ref SDS 63 DV4M  Medication side effects of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
200935 - dizziness have subsided. ref SDS 63 DV50  Dry mouth and urination have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
200936 - increased. ref SDS 63 DV56  Peripheral neuropathy related to elevated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
200937 - bilirubin has recurred. ref SDS 63 DV59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
200939 -  ..
200940 - On 140518 0920 at 2244 received letter from Doctor Alba notifying not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200941 - to get blood draw at lab prior to meeting with medical team tomorrow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200942 - morning. ref SDS 63 RW7O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
200944 -  ..
200945 - On 140520 0732 background and planning for getting supplemental labs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200946 - on electrolyte (Chem Profile), and EPC. ref SDS 65 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
200948 -  ..
200949 - On 140520 0732 at 0743 letter requests VA order electrolyte (Chem                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
200950 - Profile) lab order today. ref SDS 65 YW4H, and include lab for EPC.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
200951 - ref SDS 65 4U46  Doctor Sandhu notified that medical team in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
200952 - Francisco discusses increased urination indicates possible prostate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200953 - issues. ref SDS 65 4U95  During meeting on 140519, decided that mild                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
200954 - symptoms peripheral neuropathy possibly due to statin treatment does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200955 - not justify ending statin tratement, because treatments have been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
200956 - effective managing lipids. ref SDS 65 4U4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
200958 -  ..
200959 - On 140520 0732 at 0812 letter from VA advises Doctor Alba will order                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200960 - Chem Profile lab when she arrives at the hospital. ref SDS 65 4V5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
200962 -  ..
200963 - On 140520 0732 at 1017 VA partial lab at Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
200964 - Franciso for electrolyte (Chem) panel that was omitted on lab 140514.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200965 - ref SDS 65 KK9M  Glucose, sodium, potassium declined, with potassium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
200966 - (K 5.2) still at high end of range for Labcorp and slightly above VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200967 - range, ref SDS 65 ZG5O; bilirubin declined dramatically. ref SDS 65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
200968 - 015M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200970 -  ..
200971 - On 140520 0732 at 1028 VA letter Doctor Alba requests clarification of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
200972 - scope for EPC lab. ref SDS 65 654J  Called to explain scope of EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
200973 - lab, but encountered poor connection using cell phone. ref SDS 65 U63N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
200975 -  ..
200976 - On 140520 0732 at 1609 VA letter - Doctor Alba ordered EPC lab, she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200977 - advises EPC lab requires approval by lab staff of doctor's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
200978 - justification. ref SDS 65 AF5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200980 -  ..
200981 - On 140520 0732 at 1617 letter to VA submits justification for doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
200982 - to submit with order for EPC lab that saves lives, time, and money.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200983 - ref SDS 65 JP8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200985 -  ..
200986 - On 140522 1052 letter to Doctor Egan at Martinez submits results of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
200987 - labs on Electrolyte Chem Profile showing Potassium, which Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200988 - requested. ref SDS 66 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
200990 -  ..
200991 - On 140529 0942 letter to Doctor Alba at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
200992 - Francisco adise placed order with Release of Information Department to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
200993 - submit Progress Notes for meeting on 140519, so no need for Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
200994 - Alba so submit. ref SDS 67 X45G  Recommend correcting errors in prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
200995 - notes so they are carried forward in Progress Notes for meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
200996 - 140519. ref SDS 67 QF6T  Recommend Progress Notes cite patient support                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
200997 - to improve lipid labs past 6 months, ref SDS 67 QF67, referencing the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
200998 - lab report on 140514 0950, ref SDS 61 W25L, which also presents                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
200999 - extended exercise, weight loss, and diet changes. ref SDS 61 I17G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
201000 - Asked about progress getting approval for EPC lab. ref SDS 67 QG3U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
201001 - Request VA order coronary CT angiography with calcium score to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201002 - evaluate regression of athersclerosis, as a result of good labs from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201003 - medication and extended exercise the past 6 months. ref SDS 67 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
201005 -  ..
201006 - On 140610 0930 letter asks again about publishing Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201007 - meeting at the VA on 140519. ref SDS 68 X45G  Reminds to order EPC and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201008 - coronary CTA tests. ref SDS 68 LJ61  Customer offers to order EPC and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201009 - coronayr CTA tests in order to save time for the VA. ref SDS 68 LJ6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201010 - Report peripheral neuropathy and urination symptoms have again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201011 - subsided. ref SDS 68 LJ6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201013 -  ..
201014 - On 140610 0930 at 1115 letter from Doctor Alba advising that Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201015 - Notes for meeting on 140519, were completed last week. ref SDS 68 W84I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201017 -  ..
201018 - On 140610 0930 at 1114 letter asks Doctor Alba about progress ordering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201019 - EPC lab and coronary CTA with calcium score, ref SDS 68 KH3O, repeating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201020 - request in the letter earlier this morning, ref SDS 68 LJ61, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201021 - discussed in Doctor Alba's letter received at 1115. ref SDS 68 W84I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
201023 -  ..
201024 - On 140612 1048 VA letter notifies refuse order coronary CTA to test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201025 - for level of atherosclerosis because history of CABG surgery on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201026 - 091022, shows coronary artery disease, which VA relies upon to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201027 - speculate plaques remain in arteries, therefore, CT angiography, is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201028 - not going to add any value to your current diagnoses or treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201029 - ref SDS 69 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201031 -  ..
201032 - On 140626 1652 letter notify VA commend Doctor Alba correcting errors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201033 - in Progress Notes in prior meeting so they are not replicated in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201034 - Progress Notes for meeting on 140519. ref SDS 71 X45G  Commend VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
201035 - timely prescription refill on Ezetibime and Atorvastatin. ref SDS 71                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201036 - MY9Y  Offer to defer lab on EPC to assess prospects for regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201037 - atherosclerosis, since EPC should be favorable based on increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201038 - exercise that has increased WBC 50%. ref SDS 71 MY45  Review VA refusal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201039 - to order coronary CTA aligns with prior experience at Kaiser ordering                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201040 - CT testing to evaluate pulmonary embolism. ref SDS 71 MY51  VA grounds                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201041 - for refusing CTA testing that results will not aid care for patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201042 - with CABG surgery, conflicts with the record showing CTA is commonly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201043 - performed to assess recovery from atherosclerosis who have undergone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201044 - CABG surgery. ref SDS 71 MZ33  Request recommendations for 2nd opinions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201045 - on CTA testing. ref SDS 71 MZ82                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201047 -  ..
201048 - On 140629 1921 report side effects of prescribed care metatasalgia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201049 - causing sore feet. ref SDS 73 UZ64  Efforts to resolve without medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201050 - care have not been effective. ref SDS 73 U13R  Request referral to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
201051 - Podiatry for consultation. ref SDS 73 U14H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201053 -  ..
201054 - On 140703 1938 letter from Doctor Alba at VA in San Francisco Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201055 - Center reports detailed discussion among medical team leading and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201056 - refused to order EPC lab. ref SDS 74 X45G  The doctor recommends                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201057 - getting 2nd opinion from Doctor Egan at VA Cardiology Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201058 - Martinez on CTA testing for regression of atherosclerosis. ref SDS 74                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201059 - H233  Doctor Alba further recommends requesting from Primary Care at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201060 - VA Clinic in Martinez, referral to Podiatry to resolve metataslagia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201061 - side effects from implementing Plan of care in Progress Notes on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201062 - 140213. ref SDS 74 H240                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201064 -  ..
201065 - On 140703 1938 at 2023 letter to Doctor Alba at VA in San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201066 - Medical Center, requests details of discussion among medical team on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201067 - EPC issue. ref SDS 74 6X3V  Notify VA customer will pay for cost of EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201068 - and CTA testing, request assistance - need doctor to order tests.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201069 - ref SDS 74 6X40  Advise VA Medical Center in San Francisco that during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201070 - a meeting on 140430, Doctor Egan at VA Cardiology Clinin in Martinez,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201071 - was consulted on CTA to evaluate regression of atherosclerosis, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201072 - seemed to indicate it is impossible. ref SDS 74 6X43  Present research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201073 - showing expert opinion that regression of atherosclerosis occurs under                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201074 - conditions of elevated EPC and HDL. ref SDS 74 6X46  Present benefits                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201075 - of doing CTA test for regression of atherosclerosis. ref SDS 74 6X5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201077 -  ..
201078 - On 140703 1938 at 2023 letter to Doctor Alba at VA in San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201079 - Medical Center notfies have been unable to perform Plan of Care for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201080 - continuing physical activity prescribed in Progress Notes on 140213                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201081 - 0830, ref SDS 55 E34O, hiking 11 miles per day due to metatarsalgis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
201082 - side effects, and will implement recommendation to discuss referral to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201083 - Podiatry with Primary Care at VA Clinic in Martinez. ref SDS 74 6X57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201085 -  ..
201086 - On 140710 1348 letter from Doctor Alba offering to follow up if Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201087 - Egan in Cardiology at VA Clinic in Martinez is unable to order EPC and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201088 - CTA test for regression of atherosclerosis. ref SDS 75 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201090 -  ..
201091 - On 140710 1348 at 1353 letter to Doctor Alba with copy to Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201092 - in Cardiology at VA Clinic Martiniz, and submitting Doctor Alba's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201093 - letter earlier today, and asking Doctor Egan to order EPC and CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201094 - tests for regression of atherosclerosis. ref SDS 75 DX7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201096 -  ..
201097 - On 140710 1348 at 1353 letter to Doctor Alba with copy to Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201098 - Sandhu in Primary Care at VA Clinic Martiniz, and notifying that feet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201099 - pain from metatarsalgia preventing hiking 2 weeks (actually 3) caused                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201100 - weight increase. ref SDS 75 CA5F  Request Doctor Sandhu make referral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201101 - to Podiatry to resolve metatarsalgia; cite CVD risk without hiking,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201102 - and Half Dome hike in jeopardy. ref SDS 75 CM68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201104 -  ..
201105 - On 140710 1348 at 1353 letter to Doctor Alba advises will notify the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201106 - doctor of results requesting support from VA Clinic in Martinez.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201107 - ref SDS 75 CM72                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201109 -  ..
201110 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201111 - Metabolism Department at VA Medical Center in San Francisco, report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201112 - results work plan on 140710 - Doctor Egan in Cardiology VA Clinic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201113 - Martinez has not responded to request for ordering EPC and CTA testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201114 - to assess regression of atherosclerosis related to CVD risk.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201115 - ref SDS 0 X45G  Request Doctor Alba support order for EPC and CTA,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201116 - ref SDS 0 WL7K, as noted in the doctor's letter on 140710 1348.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201117 - ref SDS 75 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201119 -  ..
201120 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201121 - Metabolism Department at VA Medical Center in San Francisco, notified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201122 - unable to hike last 4 weeks due to rising metatarsalgia side effects.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201123 - ref SDS 0 WL6H  Weight has increased without hiking; past 3 days was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201124 - able to hike trying new shoes and orthotics. ref SDS 0 WL70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201126 -  ..
201127 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201128 - Metabolism Department at VA Medical Center in San Francisco, notified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201129 - Primary Care VA Clinic in Martinez has not had time to issue referral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201130 - for Podiatry to resolve rising metatarsalgia side effects. ref SDS 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201131 - WL6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201133 -  ..
201134 - On 140731 1048 at 1421 letter from Doctor Alba with Endocrinology,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201135 - Diabetes and Metabolism Department at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201136 - Francisco, repeats recommendation to obtain support from Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201137 - ordering EPC lab and CTA test for regression athersclerosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201138 - ref SDS 0 QU4F  The doctor complains she cannot order EPC and CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
201139 - tests, because she does not understand them, ignoring plan for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201140 - collaborating with a doctor who has this understanding for placing the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201141 - order. ref SDS 0 0V75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201143 -  ..
201144 - On 140731 1048 at 1421 letter from Doctor Alba with Endocrinology,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201145 - Diabetes and Metabolism Department at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201146 - Francisco, proposes making referral to podiatry for resolving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201147 - metatarsalgia side effects of care for regression of atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201148 - to lower risks of CVD. ref SDS 0 OV90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201150 -  ..
201151 - On 140731 1048 at 1537 letter to Doctor Alba with Endocrinology,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201152 - Diabetes and Metabolism Department at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201153 - Francisco, notifies Doctor Egan was notified twice about need for EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201154 - and CTA tests to assess regression of atherosclerosis to lower CVD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201155 - risk. ref SDS 0 GY4K  Propose defer EPC test because metatarsalgia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201156 - side effects have prevented extended exercise, so cannot get valid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201157 - test until metatarsalgia resolved. ref SDS 0 4164  Propose defer CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201158 - because VA has not had time to order test paid for by patient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201159 - ref SDS 0 4167                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201161 -  ..
201162 - On 140731 1048 at 1537 letter to Doctor Alba with Endocrinology,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201163 - Diabetes and Metabolism Department at VA Medical Center in San                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201164 - Francisco, thanks the doctor for making referral to Podiatry,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201165 - ref SDS 0 4230, and requests referral provide link to patient history                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201166 - on extended exercise that caused matatarsalgia, and requests                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201167 - submission of language in the referral. ref SDS 0 4233                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201168 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201169 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201170 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201171 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201173 -  ..
2012 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2013 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2014 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2015 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201501 - Letter to Doctor Alba at VA saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201503 -    1.  Subject:  VA Order EPC Lab and Coronary CTA with Patient Billed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201504 -        Date:  2014-07-31 11:05                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201511 -         ..
201512 -    2.  As you requested, today following up letter on 140710.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201513 -        ref SDS 75 DX7K  Have not heard from Doctor Egan, Cardiology in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201514 -        Martinez  on ordering EPC lab and coronary CTA with calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201515 -        score (at patient expense) to evaluate regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201516 -        atherosclerosis, planned in the meeting with you and Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201517 -        Feingold on 140519.  Recall this test is justified by 130% rise                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201518 -        in HDL 67 with concomitant fall in TG reported in most recent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201519 -        lab on 140514, (see lipid history line 760656, ref SDS 61 W25L,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201520 -        compared to labs when CABG was performed to resolve 4 blockages                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201521 -        5 years ago on 091022. ref SDS 4 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201523 -             ..
201524 -            [...below on 140731 1048 at 1421 letter from Doctor Alba                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
201525 -            proposes asking Doctor Egan again to support EPC and CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201526 -            testing for response to treatment achieving regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201527 -            atherosclerosis, ref SDS 0 QU4F; seems to ignore report in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201528 -            the letter today that Doctor Egan has not had time to take                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201529 -            action, per above - and so presents a loop. ref SDS 0 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201531 -         ..
201532 -    3.  The past 4 weeks have not been able to hike due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
201533 -        metatarsalgia side effects of extended exercise to raise HDL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201534 -        and EPC, and lower TG through weight loss, which together may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201535 -        drive regression of atherosclerosis, also shown with lab report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201536 -        on 140514 (see line 760574. ref SDS 61 I17G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
201538 -         ..
201539 -    4.  As well, Doctor Sandhu, Primary Care at the VA in Martinez, has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201540 -        not had time for referral to podiatry to resolve metatarsalgia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201542 -  ..
201543 - This follows up letter to Doctor Alba with copy to Doctor Sandhu on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201544 - 140710 1348. ref SDS 75 CM68                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201546 -            [...below on 140731 1048 at 1421 letter from Doctor Alba                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
201547 -            requests notice for her to make referral to Podiatry.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201548 -            ref SDS 0 OV90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
201550 -  ..
201551 - Letter to VA continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201552 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201553 -    5.  Without hiking, weight has increased.  After many trials, new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201554 -        shoes and orthotics enabled resumption of hiking the past 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201555 -        days, beginning on 140728; vitals still look okay (see line                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
201556 -        107952. [...referencing case study on 120101 0900. ref SDS 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201557 -        T56H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201559 -         ..
201560 -    6.  Your letter on 140710, discussed making inquiries about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
201561 -        ordering EPC lab and coronary CTA with calcium score from an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201562 -        outside vendor paid by the patient (see your letter on 140710                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201563 -        1348. ref SDS 75 X45G).  Since there doesn't seem to be another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
201564 -        way to get this done, please let me know if you can help.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
201565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201566 -            [...below on 140731 1048 at 1421 letter from Doctor Alba                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
201567 -            proposes asking Doctor Egan again to support EPC and CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
201568 -            testing for response to treatment achieving regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
201569 -            atherosclerosis, ref SDS 0 QU4F; seems to ignore report in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201570 -            the letter today that Doctor Egan has not had time to take                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201571 -            action, per above - and so presents a loop. ref SDS 0 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
201573 -  ..
201574 - Background on EPC issue....                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
201575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201576 -            Doctor Egan did not respond.................... 140731 1048, ref SDS 0 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201577 -            Patient requests support Doctor Egan........... 140710 1348, ref SDS 75 DX7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201578 -            VA refuse order EPC suggests ask Doctor Egan... 140703 1938, ref SDS 74 H167                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201579 -            Request progress ordering EPC lab.............. 140626 1652, ref SDS 71 MY45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201580 -            VA still pending answer on order EPC lab....... 140612 1048, ref SDS 69 Y68L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201581 -            Follow up on ordering EPC lab.................. 140610 0903, ref SDS 68 LJ61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201582 -            Follow up on ordering EPC lab.................. 140529 0942, ref SDS 67 QG3U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201583 -            Doctor Alba responds........................... 140520 0732, ref SDS 65 AF5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201584 -            Follow up letter............................... 140520 0732, ref SDS 65 4U46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201585 -            Confirm request in meeting on 140529........... 140520 0732, ref SDS 65 4U46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201586 -            Request EPC lab................................ 140515 2043, ref SDS 62 YM61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201587 -            Research EPC enables regression atherosclerosis 131125 0005, ref SDS 46 6O9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201589 -  ..
201590 - Background on CTA issue...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
201591 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201592 -            Doctor Egan did not respond.................... 140731 1048, ref SDS 0 X45G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
201593 -            Patient requests support Doctor Egan........... 140710 1348, ref SDS 75 DX7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201594 -            VA recommends 2nd opinion from Doctor Egan..... 140703 1938, ref SDS 74 H233                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201595 -            Request referral for 2nd opinion on CTA........ 140626 1652, ref SDS 71 MY51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201596 -            No grounds refuse CTA assess atherosclerosis... 140626 1652, ref SDS 71 MZ33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201597 -            CTA for CABG common assess atherosclerosis..... 140626 1652, ref SDS 71 MZ54                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201598 -            VA no grounds failure order CTA assess plaques. 140612 1048, ref SDS 69 Y68L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201599 -            Follow up on ordering CTA atherosclerosis...... 140610 0903, ref SDS 68 LJ61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201600 -            Request CTA assess atherosclerosis plaques..... 140529 0942, ref SDS 67 QG38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201601 -            Justification coronary CTA order............... 140520 0732, ref SDS 65 VQ48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201602 -            Request EPC lab predicate to CTA............... 140515 2043, ref SDS 62 YM61                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201603 -            Research CTA test regression atherosclerosis... 131125 0005, ref SDS 46 N73K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
201604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201614 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201615 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201617 -  ..
2017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2018 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2019 - 1421                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2020 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202001 - Received letter from Doctor Alba at VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202002 - and saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202003 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202004 -    1.  Subject:  RE: VA Order EPC Lab and Coronary CTA with Patient Billed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
202005 -        Date:  2014-07-31 12:53                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202012 -         ..
202013 -    2.  I really recommend that you obtain second opinion from  Dr                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202014 -        Eagan.  You should discuss the utility of a CTA  and  calcium                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202015 -        score.  As discussed before, we consider that there is no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202016 -        utility for you, since we are already know you have coronary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202017 -        artery disease and CABG, as well as elevated cholesterol and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202018 -        you are currently on therapy.  Also, you have to take into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202019 -        account the concern for exposure to unnecessary radiation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202021 -  ..
202022 - Background on CTA issue is listed above. ref SDS 0 CM64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202024 -  ..
202025 - Doctor Alba responds to the letter this morning requesting support for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202026 - EPC and CTA testing, because Doctor Egan has not had time to provide                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202027 - assistance, per above, ref SDS 0 X45G and ref SDS 0 WL7K, and by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202028 - repeating recommendation on 140710 to obtain support from Doctor Egan,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202029 - ref SDS 75 X45G - thus the VA is in a loop, refusing to perform.  VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
202030 - assertion that testing for regression of atherosclerosis to assess                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202031 - care for managing CVD risk is "without utility" because the patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202032 - has a history of atherosclerosis is inherently conflicting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202033 - standard of care to test for results of medical interventions, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202034 - further ignores prior analysis in the record on 140626 1652.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
202035 - ref SDS 71 MZ33                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202037 -  ..
202038 - VA citing concern that CTA test presents exposure to unnecessary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202039 - radiation, as grounds to refuse testing, conflicts with standard of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202040 - care to test for results of treatment.  The patient has been treated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202041 - for 5 years to recover from atherosclerosis, beginning with CABG x4 on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202042 - 091022 0700. ref SDS 4 PQWU  CTA is standard of care for CABG with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202043 - sources cited in letter to VA on 140626 1652. ref SDS 71 MZ54  An                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202044 - obvious question is what effect have post CABG interventions yielded,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202045 - since 091022, including medications and extended exercise training                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202046 - prescribed in VA Progress Notes on 140519 0800? ref SDS 64 OW76  CT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
202047 - testing is well settled standard of care for response to treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202048 - Millie had about 15 CT tests per year for 7 years, and never suffered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202049 - noticable effects.  In this case the patient previously had a CT test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202050 - on 130117 0900. ref SDS 32 LM8K  There was a previous CT the month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202051 - before on 121113 1100. ref SDS 28 4X5H  The next prior test was 5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202052 - years earlier during evaluation of post CABG surgery issues on 091030                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202053 - 0810. ref SDS 5 1N6L  Accordingly, 1 more test in a 2 year period                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202054 - presents minimal exposure to radiation, likely less than hiking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202055 - in the sunshine everyday for 5 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202057 -  ..
202058 - Letter from Doctor Alba continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202059 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202060 -    3.  Regarding EPC - although I found data on the relation of EPC to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202061 -        cardiovascular risk; we already know that you  have a history                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202062 -        of coronary vascular disease,  so again utility is not clear                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202063 -        and that is what I discussed with the lab medicine department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202064 -        when I enquired about this test in the past.  If I were to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202065 -        order a test that  I do not know how to interpret it, I am not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202066 -        sure we can conclude  that there is  any benefit to you or your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202067 -        current treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
202069 -  ..
202070 - Background on EPC issue is listed above. ref SDS 0 H33O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202072 -  ..
202073 - VA position conflicts with standard of care, reported above.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
202074 - ref SDS 0 545J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202076 -  ..
202077 - VA reliance on patient "history of coronary vascular disease" (CVD),                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202078 - as grounds for failure to test for EPC, conflicts with research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202079 - showing EPC together with elevated HDL enable regression of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
202080 - artherosclerosis, which is the best treatment for CVD, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202081 - 131125 0005. ref SDS 46 6O9M  Managing CVD risk requires testing EPC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
202082 - and HDL, and CTA with calcium score, presented to VA most recently on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202083 - 140626 1652. ref SDS 71 MZ54  Testing is not to determine whether                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
202084 - patient has CVD, but whether the condition is improving, static, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202085 - worsening, and in time to take effective action.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202087 -  ..
202088 - Letter from Doctor Alba continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202089 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202090 -    4.  You have to understand that If I order a test, I am responsible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202091 -        for the results and/or follow up.  So I am sorry, but I do not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202092 -        feel comfortable ordering these tests.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202094 -  ..
202095 - This position seems to ignore patient proposal to pay for the cost of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202096 - EPC and CTA testing, as done with Lipid NMR test to determine LDL-P,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202097 - set out in the letter on, ref SDS 74 6X40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202099 -  ..
202100 - Since testing is standard of care for evaluating response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
202101 - treatment, explained above.  Seems likely the underlying reason for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202102 - refusing EPA and CTA testing is that VA has taken policy position not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202103 - to test, because few patients achieve regression of atherosclerosis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202104 - and so the cost to suppor the few who do is not justified in relation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202105 - to simply prescribing medical drug treatment for atherosclerosis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202106 - regardless of whether any plaques remain in the blood vessels to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202107 - treat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202109 -  ..
202110 - While no physician should be pressured to resist or otherwise ignore                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202111 - hospital cost benefit policies, it is not clear why any hospital,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202112 - including the VA, should refuse to order testing for recovery from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202113 - atherosclerosis, when test results could justify reduced treatment,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202114 - cost, and wear and tear on patient health from side effects, and when                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202115 - the cost is being paid by the patient, as set out in the letter to the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202116 - VA on 140703 1938. ref SDS 74 6X40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202118 -  ..
202119 - Letter from Doctor Alba continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202120 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202121 -    5.  Since Dr Egan is your cardiologist, I think you should make an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202122 -        appointment with him to further discuss the utility of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202123 -        tests.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202125 -         ..
202126 -    6.  I think you have an appointment coming up in September in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202127 -        endocrinology clinic, so if you have any more questions, you                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202128 -        can further discuss these issues then.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202130 -         ..
202131 -    7.  Let me know if you need the referral to podiatry, I can do that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202132 -        for you.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202134 -  ..
202135 - Offer to make referral to Podiatry responds to the letter this morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202136 - notifying that increased side effects of metatarsalgia have prevented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202137 - for past 4 weeks rather than continue care with physical activity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202138 - prescribed in Progress Notes on 140213 0830. ref SDS 55 E34O and that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
202139 - Primary Care at VA Clinic in Martinez has not had time to make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202140 - referreal, per above. ref SDS 0 WL6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202142 -             ..
202143 -            [...below on 140731 1048 letter to VA notifies Doctor Alba                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
202144 -            to make referral to Podiatry. 1537 ref SDS 0 4230                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
202145 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202154 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202155 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202157 -  ..
2022 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2023 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2024 - 1537                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2025 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
202501 - Sent letter to Doctor Alba saying...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202503 -    1.  Subject:  Please Proceed Podiatry Referral                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202504 -        Date:  2014-07-31 16:13                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202512 -         ..
202513 -    2.  Responding to your letter earlier today at 1253, shown above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202514 -        ref SDS 0 X45G, your recommendation to consult Doctor Egan on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202515 -        ordering a coronary CTA test with calcium score was implemented                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202516 -        on 140430, ref SDS 57 2F6O, and again on 140710. ref SDS 75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202517 -        DX7K  Doubtless he's done all he can with a hectic schedule.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202519 -         ..
202520 -    3.  Please drop the EPC issue, and just assume I had a good number                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202521 -        OA 140514.  EPC tests are not done often, because few customers                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202522 -        get to the point of testing for regression of atherosclerosis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202523 -        Since it is not a common test, it is likely expensive.  While                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202524 -        best practice would test for elevated EPC and HDL, then test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202525 -        for regression of plaques, since I have been unable to hike for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202526 -        a month, EPC probably won't test well anyway at this time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
202528 -         ..
202529 -    4.  Coronary CTA with calcium score tests for results of therapy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202530 -        treating atherosclerosis (CAD, CVD) with medication and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202531 -        exercise, including weight loss.  Favorable results can reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202532 -        the cost of care, and further reduce wear and tear from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
202533 -        extended training, which reached critical mass last month.  I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202534 -        assume you have asked around and cannot find a direct, simple                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202535 -        way to get an order issued within the VA for the customer to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202536 -        pay the cost of an outside lab, as done with NMR lipids.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202537 -        Therefore, let's drop CTA issue at this time.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202539 -  ..
202540 - This responds to Doctor Alba's notice that VA refuses to order CTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202541 - paid by patient, because there is no "utility," ref SDS 0 QU4F; and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202542 - further resolves VA quandry about how to interpret EPC and CTA tests,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202543 - as causing hestancy ordering the tests, presented in her letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202544 - earlier today, per above. ref SDS 0 0V75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202546 -  ..
202547 - Since the VA is not paying for the test, there is no duty to interpret                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202548 - results, and indeeed results need not be presented to the VA.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202549 - has been no similar complaint about VA getting results of Lipid NMR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202550 - test results, which the VA refused to order, but which were paid by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202551 - the patient and submitted to the VA, shown in composite lab report on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202552 - 140514 0950. ref SDS 61 IM9N  CT test results are interpreted by a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202553 - professional experienced with this work.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
202555 -  ..
202556 - Letter to Doctor Alba continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202558 -    5.  Thanks for making referral to podiatry.  While some progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202559 -        has been made, work should be guided by professional medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202560 -        advice.  A few weeks ago, seemed that Half Dome was not going                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202561 -        to be possible in September.  Based on improvement the past few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202562 -        days, I'm more hopeful now, even though had to stand down on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202563 -        hiking today with sore feet again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
202565 -  ..
202566 - This responds to Doctor Alba's letter today, with last paragraph                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202567 - offering to make referral to Podiatry, per above. ref SDS 0 OV90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
202569 -  ..
202570 - Letter to Doctor Alba continues...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
202571 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202572 -    6.  In making referral please provide patient history reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202573 -        metatarsalgia, shown in case study on 120101 beginning line                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202574 -        107952. ref SDS 18 T56H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202576 -         ..
202577 -    7.  Referral should remind that this is a big record, and so can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202578 -        take 30 - 90 seconds to read into the browser.  Naturally, I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
202579 -        will understand if no citation to the record is provided, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
202580 -        remain very grateful for your referral to podiatry.  Please                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
202581 -        submit the precise language presented in the referral in order                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
202582 -        to be prepared for the doctor's awareness of issues.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
202584 -         ..
202585 -    8.  Thanks again very much for your help.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
202586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202592 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202593 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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202596 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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202600 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202601 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202602 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
202605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2027 -