KARE 11 Investigates: Whistleblower warnings ignored. Wounded Veterans misdiagnosed.
A KARE 11 investigation exposes Veterans misdiagnosed by the same doctor while the VA turned a blind eye and denied benefits.
“I didn’t realize how bad I was until after I got out,” said Steve Rhodes, remembering the improvised explosive device (IED) blasts he survived in Iraq.
The Marshfield, WI man’s service records document numerous reports of headaches and memory issues dating back to 2004.
He’s quick to acknowledge he’s not sure what path he would be on without the VA doctors who helped him navigate the dark days. “I don’t know where I would be today,” he said.
But ask him about one particular doctor at the Tomah VA and you might just hear some language that would make a drill instructor blush.
“Everybody warned me about her,” he said, recalling his first compensation and pension exam in 2011 with Tomah VA neurologist Mary Jo Lanska.
Before that exam, records show Rhodes had been diagnosed by a VA neurologist with a Traumatic Brain Injury (TBI). Despite that, Dr. Lanska wrote that he had no TBI diagnosis.
As a result, he has been denied benefits for the injury for the past 12 years.
He’s not alone.
For more than a year, KARE 11’s Broken Promises investigation has exposed how Dr. Lanska’s seemingly routine and obvious misdiagnosis of Veterans during brief compensation and pension exams have resulted in denied benefits.
In some cases, medical care itself has been denied.
Rhodes saw KARE’s reporting and reached out to share his story.
“I’m not much for being in front of the cameras,” he said. “And I don’t want all the publicity or anything coming, it’s just not right what she’s doing!”
EDITOR'S NOTE: Veterans who believe they were impacted by the Tomah VA’s flawed exams exposed in this report are urged to call a special VA hotline: 608-372-3971 extension 64775.
Chapter 1: Clear and Unmistakable Errors
Rhodes served two tours in Iraq as a motor vehicle operator where his records show he hit his head on a vehicle in the dark so hard it required sutures, and he was also exposed to multiple IED blasts.
Rhodes recalls the closest explosion was right beside his vehicle while he was standing out the top as a gunner manning the .50 caliber machine gun. He says the blast went off on the same side he was facing.
He remembers seeing a lot of stars and by the time they got back to base his entire body was shaking as if he was having a seizure.
“You can’t make your body shake that way,” he said. “It’s very hard to explain what my body was going through. It’s like nothing I’ve ever experienced before.”
Rhodes says that’s where a lot of his medical problems started. To this day, he suffers debilitating headaches and migraines daily and averages about 12 ER visits a year when the pain becomes unbearable.
In 2011, a neurologist on the polytrauma team at the Tomah VA confirmed he had a diagnosis of Traumatic Brain Injury (TBI).
Three months later he was sent for a Compensation and Pension Exam to determine his benefits. That’s where he first met Dr. Mary Jo Lanska.
Rhodes recalls the exam lasted no more than 20 minutes. In that time Dr. Lanska decided to overrule all the other medical professionals who’d seen him. She put in his records that he didn’t even have a TBI.
Because of her finding, he was denied benefits.
Years later, in 2018, he applied for benefits specifically for the headaches that routinely put him in the hospital and again was sent to see Dr. Lanska.
“She said my headaches and migraines were not combat related or service-connected even though it’s in my medical records like 29 times before I even got out,” Rhodes said.
He was again denied.
When KARE 11 began reviewing Rhodes' files, it was obvious there were mistakes denying the combat Veteran the benefits he deserved.
KARE 11 wrote to Kim Graves, Director of the St. Paul Regional Office of the Veterans Benefits Administration (VBA) and asked for a high-level review of Rhodes’ case.
A few weeks later, Steve Rhodes received a benefits decision letter. It stated a review of his case found “clear and unmistakable errors … that are undebatable.”
He’s now receiving TBI and headaches benefits backdated to when he first applied and was denied – more than 12 years ago – as a result of the exam by Dr Lanska.
“I appreciate you guys looking into this,” Rhodes said. “Investigating this, calling this out, because it’s not right.”
Unbeknownst to Rhodes, the Tomah VA was warned – in writing – years ago that Dr. Lanska was wrongly misdiagnosing and denying benefits for Veterans.
A KARE 11 investigation finds the Tomah VA turned a blind eye, even to a Veteran’s death.
Chapter 2: The Whistleblower
In Block D at the Lakeview Cemetery in Rib Lake, Wisconsin, Vietnam Veteran Donald Monheim is buried alongside his parents.
He died while still fighting his last battle, this time with the government agency that was supposed to care for him.
“This just isn’t right!” said Jeff Hein while telling Monheim’s story to KARE 11.
Hein, now retired, served six years as the Taylor County, WI Veterans Service Officer (CVSO).
He tried telling the story of what was done to Monheim and other Veterans to leadership at the Tomah VA Hospital more than five years ago.
No one listened, he said.
“When a problem is identified, it has to be addressed,” Hein said. “This problem has been identified for quite some time and it’s never been addressed!”
Monheim was exposed to Agent Orange and other dioxins in Vietnam.
In 2009, records show, the Veteran was diagnosed with Parkinson’s and began being treated for the disease by private doctors at the Marshfield Clinic.
For Vietnam Veterans exposed to Agent Orange, Parkinson’s is what’s known as a presumptive illness – automatically qualifying them for VA benefits.
In 2016, Jeff Hein helped file a VA claim for the sick, elderly Veteran who had no wife or children.
The case seemed to be a slam dunk.
“So, all he had to prove was he was in Vietnam and now he had Parkinson’s,” explained Hein, “That’s all he had to do, and that was denied!”
Records show Monheim was examined at the Tomah VA by neurologist Mary Jo Lanska during a brief compensation and pension exam.
What seemed like a slam dunk case became a prolonged and ultimately losing battle when Dr. Lanska decided all the Veteran’s other doctors who had diagnosed and treated him for years were wrong.
Dr. Lanska concluded Monheim did not even have Parkinson’s.
She wrote in her records, “Alternative diagnosis better fit the clinical picture.”
Because Dr. Lanska claimed Monheim did not have Parkinson’s, his benefits claim was denied.
Monheim appealed, providing letters from his private doctors stating that he did indeed have Parkinson’s.
Months later, with the appeal still undecided, Monheim died.
On his death certificate, “Parkinson’s” is listed as a contributing factor.
Jeff Hein had seen enough. He’d had other Veterans go to the Tomah VA for benefit exams and see Dr. Lanska. He says they were all denied.
So, Hein blew the whistle.
He wrote a letter to Tomah VA leadership following Monheim’s death in August of 2017 spelling out what had happened. He also detailed the cases of several other Veterans similarly denied “with one common denominator: Dr. Mary Jo Lanska.”
Dr. Lanska, Hein wrote, “… seems to have a tendency to re-diagnose from the C&P exam room, counter to documented opinions of other, more accredited doctors.”
Hein’s letter called on Tomah VA leadership to review the other Veterans' cases he presented to determine their correctness. He also asked for a broader review of Dr. Lanska’s exams.
“The only message I ever got back is, ‘It’s being looked into,’” Hein said.
Apparently, nothing changed.
Since Hein’s letter, KARE 11’s investigation has exposed how Veterans continued to be misdiagnosed, denied benefits and sometimes medical care itself because of the actions of Dr. Lanska.
Determining exactly how many Veterans were misdiagnosed or denied benefits after an exam by Dr. Lanska has proven elusive.
Data obtained by KARE 11 through a Freedom of Information Act (FOIA) request revealed from 2012 until present, Dr. Lanska did exams tied to 786 disability claims. However, VA told KARE 11 it would be too much work to provide data that could reveal how many of those claims were denied.
Dr. Lanska conducted benefits exams dating back to at least 2002 according to the House Committee on Veterans’ Affairs.
On April 21st, Congressmen on that oversight committee wrote a letter to the Inspector General calling for a “thorough and detailed” investigation of what KARE’s reporting has exposed.
“Is there any sense of how many men and women this could impact?” KARE 11’s Lagoe asked Jeff Hein.
He responded, “That’s a question that I’ve asked myself for years.”
Chapter 3: The Turret Gunner
Logan Becker is one of the Veterans whose case Hein asked the Tomah VA to review.
They never did.
Becker, a Marine, was awarded the Purple Heart on July 31st, 2010, for injuries sustained in Afghanistan.
Since then, he’s battled a host of issues including sleepless nights, sudden drastic mood swings, and debilitating headaches.
“They’ll put me right down,” he said of the headaches. “I just go upstairs and crawl under the blanket and I don’t move.”
Logan’s service and VA records reveal he suffered three significant blows to the head, in a period of three months, while serving in Afghanistan.
The first happened when a sandstorm brought a large tent support beam crashing down. Becker was knocked unconscious.
In the ensuing months, his armored personnel carrier on two different occasions drove over improvised explosive devices (IEDs) while Becker was operating as turret gunner – standing out of the top hatch.
He says he banged his head hard during the first IED explosion but did not lose consciousness.
The second bomb sent him flying.
He remembers an explosion – but not much else as he was ejected out the top of his MRAP landing some distance away. His knowledge of the event comes from the stories of his fellow Marines with him that day.
Becker says he has vague recollections of coming to in a medivac helicopter when an IV was placed in his arm. Waking in a panic, he punched a female medic and lunged for a rifle before the crew jumped on top of him.
He remembers the pain when they landed on his cracked ribs. “That was the most excruciating pain I’ve ever felt in my life,” he said, “I woke up the next morning in the hospital in Afghanistan and I felt like I went one round with Mike Tyson.”
He came home to Wisconsin with the Purple Heart, a pounding head, and a host of other symptoms a VA psychologist attributed partly to PTSD and partly to a TBI.
He was sent for a TBI compensation and pension exam on September 28th, 2011, at Tomah VA where he was examined by Dr. Mary Jo Lanska.
“I spent about 5 minutes in her office,” Becker recalls.
His VA records show in that brief exam Dr. Lanska determined his brain had recovered from the three documented battle blows and his headaches and other symptoms were all due to “irregular sleep,” not “his IED exposure.”
Instead of the IED blasts and TBI, Dr. Lanska opined Becker’s irregular sleep was due to his part-time DJ job. She claimed helping a buddy do weekend weddings which required him to stay up late was the primary reason for all his sleepless nights.
His TBI benefits were denied.
Fast forward five years to 2016, Becker was still experiencing all the same symptoms and no longer worked for the DJ service. Another VA psychologist documented that Becker not only had a TBI but that, “his cognitive functioning appears to be impaired due to TBI exposure.”
However, citing Dr. Lanska’s prior exam, and labeling it, “medical evidence,” the Veterans Benefits Administration again refused to provide TBI benefits.
“Denied, denied, denied,” Becker said, the frustration evident on his face more than a dozen years after his one and only meeting with Dr. Lanska.
“When you start hearing that this isn’t just you, that this has happened to Veteran, after Veteran, after Veteran who’s seen Dr. Lanska,” KARE 11 asked, “What do you think?”
Becker paused, and responded, “I think we all got f****d!”
Chapter 4: Senators Demand Answers
Over the past year, KARE 11 has been requesting interviews with Tomah VA Medical Center Director Karen Long and VA leadership including VA Secretary Denis McDonough, a Minnesota native.
They have refused KARE 11’s multiple requests for an interview to discuss what our Broken Promises investigation was uncovering.
Despite repeated requests, Dr. Lanska herself never responded to email or voicemail. When KARE 11 recently knocked on the door of her home, she closed the door refusing to answer any questions.
After KARE 11 began reporting about problems at Tomah, U.S. Senator Tammy Baldwin of WI began demanding answers.
In August 2022, Senators Baldwin and Tammy Duckworth (D-IL) sent a letter to Secretary McDonough highlighting their concerns about TBI misdiagnosis at the Tomah VA and pushing for answers about the process for Veterans who may have been improperly diagnosed and not receiving the benefits they deserve.
The initial response the Senators received from Glenn Johnson, Principal Deputy Assistant Secretary for Congressional and Legislative Affairs, stated, the agency had done an analysis of Dr. Lanska’s Compensation and Pension exam findings to determine if there is a trend of negative opinions. On December 28th, 2022, Johnson wrote to the Senators, “No trends of negative opinions were identified.”
Despite VA’s claims, Senator Baldwin’s office and KARE 11 continued to hear from Veterans and County Veterans Service Officers (CVSOs) with allegations of misdiagnosis and bizarre benefits denials tied to exams by Dr. Lanska.
In March of 2023, Senator Baldwin met directly with VA Secretary McDonough to express her continued concerns and press for an investigation into the Tomah VA doctor and her history of faulty exams.
“We have a commitment to do right by those who served our country, and right now, I am concerned that the VA is not holding up their end of the bargain with some of our Wisconsin Veterans," Baldwin said in a statement.
What the VA describes as a comprehensive, independent, external review was launched.
What that review found changed everything.
Chapter 5: The Review
“I think it’s really important that we’re transparent as an organization about what’s going on,” said Dr. Daniel Zomchek, the new Director of VISN 12 – a multistate region of VA hospitals including Tomah.
Dr. Zomchek sat down for an interview with KARE 11 in early April to reveal the findings of the independent review commissioned into Dr. Lanska’s exams.
Zomchek explained the VA sent a random selection of 72 of Lanska’s benefits exams to be reviewed by three neurologists outside the region.
The results came back showing 22 of the exams – or 31% -- were done incorrectly.
“And that’s a problem!” Zomchek said. “That’s not ok, that’s not meeting my expectations.”
Veterans Affairs has now launched a special hotline for impacted Veterans to call to have their case reviewed.
Zomchek also committed to having Dr. Lanska’s cases reviewed one by one to determine if a reevaluation is needed.
“Whatever it takes to do the right thing for the Veteran,” he said.
And why hadn’t the VA acted on earlier complaints?
When asked about the 2017 whistleblower letter Jeff Hein sent asking for a review of Dr. Lanska’s decisions, Zomchek said they could find no record of receiving it.
“The letter you’re referring to, dated in 2017, we received just recently actually from your office in preparation of this meeting,” Zomchek said. He added, “But we are looking into that now of course.”
During an April 27 press conference, VA Secretary Denis McDonough was asked about the findings of KARE’s reporting on the Tomah VA.
“I'm familiar with the reporting,” he responded, “because it's my hometown news reporting organization.”
He added, “I’m intimately familiar with it and we’re staying on top of this to ensure that our Veterans get the care that they have earned and deserve…we’re looking at the full range of C&P exams as well as care provided in the Tomah facility.”
Logan Becker, the Marine turret gunner denied TBI benefits due to Lanska’s exam has already received a call to begin scheduling a new exam.
Chapter 6: Still Practicing
In a move Veterans and their advocates describe as pouring salt in the wound, Dr. Lanska was initially allowed to continue seeing and treating Veterans at the Tomah VA.
“This is not an indictment on Dr. Lanska and her practice,” VISN 12 Director Zomchek told KARE 11 during an April 5 interview. “Dr. Lanska provides high-quality care, she has been doing so for many years.”
Veterans Affairs treats compensation and pension (C&P) exams as an administrative process, separate from actual medical care. According to Zomchek, Dr. Lanska stopped doing C&P exams at the start of the pandemic in March 2020.
He says VA has consistently reviewed Lanska’s actual clinical care and she has always been up to standards.
That is despite KARE’s investigation finding Dr. Lanska denied actual medical care to Veterans like Brandon Winneshiek.
Records show she first misdiagnosed him in a C&P exam. Using what other medical experts describe as inadequate testing, she claimed the combat Veteran who survived multiple explosive blasts did not a have TBI.
Years later, during a medical consult, she refused to even write a referral for him to get actual neurological testing or imaging done outside the VA. “You do not have a TBI,” the consult denial letter received by Winneshiek states.
The Veteran paid out of pocket for private testing.
Those tests showed he has a TBI.
To date, KARE 11 has interviewed two other Veterans who were forced to seek medical care in the private sector after Dr. Lanska similarly misdiagnosed their conditions without even running tests.
Senator Baldwin on April 21 again wrote to the VA Secretary about Dr. Lanska, “As my office has engaged with Veterans impacted by Dr. Lanska’s faulty examination in the C&P process, there has been increased concern that the inadequacies of her care go beyond the C&P exam process and into her clinical work.”
According to the Senator’s office, Dr. Lanska is no longer allowed to provide medical care to Veterans pending the outcome of a special review by the VA’s National Credentialing team of neurologists.
“It’s about time!” said Veteran Brandon Winneshiek.
EDITOR'S NOTE: Just as this article was published, KARE 11 received a statement from VA Press Secretary Terrence Hayes: “Dr. Lanska no longer conducts C&P exams and is not seeing patients at VA currently. Our top priority remains the delivery of world-class care and timely access to benefits to the Veterans we serve. Plans are in place to ensure that Dr. Lanska’s reassignment does not impact or interrupt this mission.”
Veterans who believe they were impacted by the Tomah VA’s flawed exams exposed in this report are urged to call a special VA hotline: 608-372-3971 extension 64775.