M21-1, Part III, Subpart iv, Chapter 3, Section A – Examination Requests Overview

In This Section

Introduction

• who may request an examination
• definition of an appropriate examination facility
• jurisdiction over examination requests for foreign resident claimants or beneficiaries
• mandatory use of the Examination Request Routing Assistance (ERRA) tool
• when an examination or opinion is necessary
• definition of
  • general medical examination
  • specialty examination, and
  • specialist examination
• Veteran’s legal rights at an examination, and
• contract examination exclusions.

Change Date

III.iv.3.A.1.a.  Who May Request an Examination

III.iv.3.A.1.b.  Definition: Appropriate Examination Facility

• mandatory use of the Examination Request Routing Assistant (ERRA) tool, see M21-1, Part III, Subpart iv, 3.A.1.d
• jurisdiction for examinations of foreign resident beneficiaries, see M21-1, Part III, Subpart iv, 3.A.1.c
• examinations of VA-employee claimants, see M21-1, Part III, Subpart iv, 3.B.1.b, and
• examinations of employees who work at an examining facility, see M21-1, Part III, Subpart iv, 3.B.1.c.

III.iv.3.A.1.c.  Jurisdiction Over Examination Requests for Foreign Resident Claimants or Beneficiaries

• permanent transfer of claims folders, see M21-1, Part III, Subpart ii, 5.D.1
• responsibility for handling requests for foreign field examinations, see M21-1, Part III, Subpart vi, 8.8.f, and
• fiduciary hubs of jurisdiction, see M21-1, Part III, Subpart v, 9.A.1.d.

III.iv.3.A.1.d.  Mandatory Use of the ERRA Tool

• 10 VA examination facilities nearest the ZIP code entered, and/or
• contract examiner associated with the ZIP code entered, if applicable.

• The ERRA tool’s use is not required at Integrated Disability Evaluation System (IDES) or Benefits Delivery at Discharge (BDD) intake sites where existing agreements specify the provider(s) responsible for local IDES or BDD examinations.
• The ERRA tool’s use is not required for requests involving
  • examination clarification
  • examination addenda
  • corrections to insufficient/inadequate examinations, or
  • acceptable clinical evidence (ACE) examinations completed by a VHA practitioner assigned to serve the RO.

• the ERRA tool, see M21-1, Part III, Subpart iv, 3.A.2.b and c
• converting documents to a portable document format (PDF) for upload, see M21-1, Part III, Subpart ii, 4.G.2.b
• the ACE examination process, see M21-1, Part III, Subpart iv, 3.A.4, and
• handling unique situations involving requests for examinations of IDES participants, see M21-1, Part III, Subpart i, 2.D.6.

III.iv.3.A.1.e.  When an Examination or Opinion Is Necessary

• M21-1, Part I, 1.C.3
• 38 CFR 3.326, and
• 38 CFR 3.159(c)(4).

III.iv.3.A.1.f.  Definition: General Medical Examination

• document normal findings, or
• identify disabilities that are found or suspected.

• general medical examinations, see M21-1, Part III, Subpart iv, 3.A.5, and
• general medical examination DBQs, see the DBQ Switchboard.

III.iv.3.A.1.g.Definition:  Specialty Examination

• Specialty examinations generally do not address disorders that are not at issue in the claim, even if the disorders are found or suspected during the examination.
• Specialty examinations may be (and usually are) performed by non-specialist clinicians, but in unusual cases, or as requested by a Board of Veterans’ Appeals (BVA) remand, it may be necessary for the specialty examination to be performed by a specialist.

III.iv.3.A.1.h.Definition: SpecialistExamination

• All vision, hearing, dental, and psychiatric examinations must be conducted by a specialist.
• In unusual cases, or as requested by a BVA remand, it may be necessary to request a specialist examination for other types of disabilities.

• specialist examinations, see M21-1, Part III, Subpart iv, 3.A.6, and
• examination report requirements, see M21-1, Part III, Subpart iv, 3.D.2.

III.iv.3.A.1.i.  Veteran’s Legal Rights at an Examination

• be accompanied by counsel during an examination, or
• record an examination.

III.iv.3.A.1.j.  Contract Examination Exclusions

Introduction

• tools used for requesting examinations
• ERRA tool
• interpreting the ERRA tool’s results 
• Index of DBQ/Exams by Disability tool
• Exam Request Builder (ERB) tool
• Simplified ERB (ERB-S) tool, and
• selecting the appropriate application for entering examination requests, and
• mandatory entry of requestor’s contact information.

Change Date

III.iv.3.A.2.a.Tools Used for Requesting Examinations

• identify the examining facility location closest to the Veteran
• identify the DBQs for the claimed disabilities
• build the examination request, and
• enter the examination request to the VA or VA contract examination facility.

III.iv.3.A.2.b.ERRA Tool

• application to use for submitting the examination request
• facility routing location
• the routing location and exam list comments
• exam type details, and
• approximate distance (from the ZIP code entered, including driving distance and estimated time).

• claimant preferences, or
• topography/driving concerns.

• The ERRA tool identifies whether a VA facility has capacity to complete examinations timely and suggests a contract provider/vendor be used if necessary.
• Any justifiable deviation from the ERRA tool’s recommendations must be explained as a remark in the examination request’s body.

• appropriate application for entering examination requests, see M21-1, Part III, Subpart iv, 3.A.2.g, and
• ERRA tool, see the Disability Examination Program Managementpage.

III.iv.3.A.2.c.  Interpreting the ERRA Tool’s Results

III.iv.3.A.2.d.Index of DBQ/Exams by Disability Tool

III.iv.3.A.2.e.  ERB Tool

• Use of the ERB tool is mandatory when creating a(n) examination or medical opinion request in CAPRI for a compensation claim.
• As with all automated tools, users should ensure the suggested language and examinations are adequate before inputting the exam requests.  This includes ensuring that the ADDITIONAL EXAM REMARKS field of the ERB is completed to include information needed by the examiner but not automatically generated by the tool.

III.iv.3.A.2.f.ERB-S Tool

III.iv.3.A.2.g.Selecting the Appropriate Application for Entering Examination Requests

III.iv.3.A.2.h.  MandatoryEntry of Requestor’s Contact Information

• first and last name
• e-mail address, and
• 10-digit telephone number.

• The telephone number provided must be one that is accessible during any authorized periods of telework the requestor may perform.
• Examination scheduling requests prepared and submitted through VBMSdo not require inclusion of the primary requestor’s contact information, as any subsequent clarification the contract examination provider/vendor deems necessary will be requested electronically.

Introduction

• definition of DBQs, and
• use and acceptance of DBQs for VA examinations and opinions.

Change Date

III.iv.3.A.3.a.  Definition:  DBQs

• elicit medical information needed to make decisions on claims, and
• provide a standardized report format for medical examinations and opinions.

• DBQs, see
  • VA’s Forms website, and
  • the DBQ Switchboard, and
• DBQs submitted from a health care provider, see M21-1, Part III, Subpart iv, 3.D.2.d and e.

III.iv.3.A.3.b.  Use and Acceptance of DBQs for VA Examinations and Opinions

• a DBQ, other medical report, or medical opinion completed by a VA or private health care provider, or
• examination results not reported using a DBQ if the DBQ, examination, medical report, or opinion includes the findings and conclusions necessary to make the needed regulatory determinations on the issues, as described in 38 CFR 3.326 and 38 CFR 4.2.

References:  For more information on

• examination requirements and insufficient exams, see M21-1, Part III, Subpart iv, 3.D
• DBQs completed by VA or non-VA health care providers, see M21-1, Part III, Subpart iv, 3.D.2.d and e
• authenticity of DBQs, see M21-1, Part III, Subpart iv, 3.D.2.f
• returning examination reports as insufficient for rating purposes, see
  • M21-1, Part III, Subpart iv, 3.D.3, and
  • the
    • CAPRI User Manual, and/or
    • VBMS User Guide
• evaluating evidence generally, see M21-1, Part III, Subpart iv, 5, and
• VA’s authority to develop for all evidence sufficient to render an informed decision, see Douglas v. Shinseki, 23 Vet.App. 19, 24, 25-26 (2009).

Introduction

• examinations based on ACE
• categories of examinations for which the ACE process is prohibited, and
• examination requests and ACE.

Change Date

III.iv.3.A.4.a.Examinations Based on ACE

III.iv.3.A.4.b.Categories of Examinations for Which the ACE Process Is Prohibited

• exams when necessary electronic medical records are not available for examiner review
• IDES or the BDD pre-discharge program
• exams required by BVA remands
• general medical examinations
• female sexual arousal disorder (FSAD) exams, and
• mental disorder examinations, including medical opinions for claimed conditions secondary to an SC mental disorder.  This specifically applies tophysical secondary conditions related to SC mental disorders, such as bruxism.

• homeless Veterans, and/or
• the following conditions:
  • hearing loss
  • tinnitus
  • cardiac conditions
  • amyotrophic lateral sclerosis (ALS), and
  • any terminal condition.

III.iv.3.A.4.c.Examination Requests and ACE

• specifies that the ACE process is permitted, or
• clearly states that the ACE process may not be used, and an in-person examination is required to complete the DBQ.

• VBA has updated the DBQ templates in CAPRI to include the ACE check boxes that contain the rationale for the use of ACE, requiring the clinician to identify the materials relied on when using ACE to prepare the DBQ.
• The ERB contains the appropriate ACE language to include in the CAPRI examination request.

Introduction

• when to request a general medical examination
• when a general medical examination is not necessary
• conducting a general medical examination, and
• citing medical conditions to be examined.

Change Date

III.iv.3.A.5.a.  When to Request a General Medical Examination

• an original claim is received within one year of discharge, or
• an intent to file (ITF) is received within one year of discharge, and a substantially complete application is received within one year of the ITF.

• individual unemployability (IU)
• service connection (SC) under 38 CFR 3.317, or
• Veterans Pension.

• ITF, see
  • 38 CFR 3.155(b), and
  • M21-1, Part III, Subpart ii, 2.C.2
• specialist examinations, see M21-1, Part III, Subpart iv, 3.A.6
• requesting exams related to claims for IU, see M21-1, Part IV, Subpart ii, 2.F.2.d
• when a rating determination of P&T disability for pension purposes is required, see M21-1, Part V, Subpart i, 2.2.e
• acceptable medical evidence for pension rating purposes, M21-1, Part V, Subpart i, 2.2.f, and
• when a VA examination is authorized for pension cases, see M21-1, Part V, Subpart i, 2.2.g.

III.iv.3.A.5.b.  When a General Medical Examination Is Not Necessary

• an original claim for compensation is being rated many years after separation from service, or
• a Veterans Pension claim that requires a P&T disability determination contains sufficient medical evidence to decide the claim.

III.iv.3.A.5.c.  Conducting a General Medical Examination

• all disabilities listed in the examination request, and
• any other disabilities the Veteran identifies during the examination.

III.iv.3.A.5.d.  Citing Medical Conditions to Be Examined

Introduction

• examinations routinely performed by specialists
• who may request other types of specialist examinations
• when to request a specialist examination, and
• who determines the choice of examiner.

Change Date

III.iv.3.A.6.a.  Examinations Routinely Performed by Specialists

• hearing
• vision
• dental, and
• psychiatric.

III.iv.3.A.6.b.  Who May Request Other Types of Specialist Examinations

• the development or rating activity
• the medical examiner, or
• BVA.

III.iv.3.A.6.c.  When to Request a Specialist Examination

• if an issue is unusually complex
• if there are conflicting opinions or diagnoses that must be reconciled, or
• based on a BVA remand.

III.iv.3.A.6.d.  Who Determines the Choice of Examiner

• Board-certified specialist in …, or
• specialist who is Board qualified.

Introduction

• who may request a medical opinion
• referring claims for complex medical opinion review
• completing the medical opinion request in CAPRI
• procedure for identifying the evidence in a medical opinion request in the ERB tool
• maintaining objectivity in medical opinion requests
• medical opinions required for remands
• instructions for providing medical opinions – claims under 38 U.S.C. 1151
• medical opinions in the Hearing Loss and Tinnitus Disability Benefits Questionnaire, and
• avoiding asking for legal conclusions in medical opinion requests.

Change Date

III.iv.3.A.7.a.  Who May Request a Medical Opinion

• compensation under 38 U.S.C. 1151
• aggravation (including Allen aggravation)
• diagnostic variation or conflicting medical evidence
• questions of credibility of evidence presented to the examiner, or
• any other matters specified by the VSCM or PMCM, such as
  • rare disorders/rare etiologies, or
  • sensitive or high priority claims.

• A VSCM or PMCM may authorize a medical opinion in any case in which he/she believes it is warranted.
• Generally, any development activity employee or MSC may order an examination using the Hearing Loss and Tinnitus Disability Benefits Questionnaire, which includes certain routine etiology opinions.  However, in cases where (1) a separate medical opinion DBQ is required to solicit an opinion not included on the audiological DBQ, or (2) the type of opinion needed is consistent with one of the “complex” exceptions identified above, the opinion request should be prepared by the rating activity.
• Most medical opinions regarding secondary causation are considered of sufficient simplicity to be requested by the development activity without rating oversight.  When, however, a Veteran contends entitlement on the basis of Allen aggravation, or a secondary claim is accompanied by competent medical evidence of the contended disability, such that aggravation may be implicated, follow the procedures in M21-1, Part III, Subpart iv, 3.A.7.b, to refer the claim for complex medical opinion review.

• determining when an examination or medical opinion is necessary, see M21-1, Part I, 1.C.3.b-i
• medical opinions and the Hearing Loss and Tinnitus Disability Benefits Questionnaire, see M21-1, Part III, Subpart iv, 3.A.7.h, and
• medical opinion training requirements, see M21-3, Part I, A.3.h.

III.iv.3.A.7.b. Referring Claims for Complex Medical Opinion Review

• special issue indicators, see M21-4, Appendix C, Section III, and
• tracked items, see M21-4, Appendix D, Section I.

III.iv.3.A.7.c.  Completing Medical Opinion Requests Using the ERB Tool

• exam request, see M21-1, Part III, Subpart iv, 3.A.9, and
• medical opinion request in CAPRI, see the CAPRI User Manual.

III.iv.3.A.7.d.Procedure for Identifying the Evidence in a Medical Opinion Request in the ERB Tool

• ASSOCIATED EXAM
• EVIDENCE
• TAB NAME
• DATE
• DESCRIPTION, and
• LOCATION.

• ERB fields, see the ERB User Guide
• requirement to identify relevant evidence for an examiner’s review, seeM21-1, Part III, Subpart iv, 3.A.8.d, and
• annotating or bookmarking evidence in the electronic claims folder (eFolder), see M21-1, Part III, Subpart iv, 3.A.8.e and f.

III.iv.3.A.7.e.Maintaining Objectivity in Medical Opinion Requests

• Use a neutral and unbiased tone.
• Do not slant the facts.
• Do not communicate that VA prefers one answer or outcome over another.

• requesting a medical opinion in an impartial manner, see Douglas v. Shinseki, 23 Vet.App. 19, 24, 25-26 (2009), and
• the attitude of rating officers, see 38 CFR 4.23.

III.iv.3.A.7.f.Medical Opinions Required For Remands

III.iv.3.A.7.g. Instructions for Providing Medical Opinions – Claims Under 38 U.S.C. 1151

III.iv.3.A.7.h.  Medical Opinions in the Hearing Loss and Tinnitus DBQ

• Do not request a separate medical opinion DBQ unless a medical opinion that is not included on the Hearing Loss and Tinnitus Disability Benefits Questionnaire is needed.
• The claims folder should be sent when an etiology opinion or other opinion is required.

• who may request a medical opinion, see M21-1, Part III, Subpart iv, 3.A.7.a, and
• the body and content of the DBQ for hearing loss and tinnitus, see theHearing Loss and Tinnitus Disability Benefits Questionnaire.

III.iv.3.A.7.i.  Avoiding Asking for Legal Conclusions in Medical Opinion Requests

• Do not request the medical authority to determine if there is loss of use of an extremity.  Instead, ask for a description of the remaining function of the extremity.
• Do not ask the medical authority to determine if a particular disability is “service-connected” or “SC.”  Instead, identify the in-service injury, event, or illness, as well as current disability, and ask the examiner to provide an opinion as to whether or not the current disability was caused by or the result of the identified in-service injury, event, or illness.
• Do not ask the medical authority to provide an opinion as to whether a Veteran is “unemployable” or “entitled to individual unemployability.”  Instead, in the Remarks section of the examination request, ask the examiner to comment on the Veteran’s ability to function in an occupational environment and to describe functional limitations.

Introduction

• importance of claims folder review
• examinations requiring claims folder review
• requesting examiner review of the claims folder
• requirement to identify relevant evidence for the examiner’s review
• bookmarking documents for examiner review, and
• annotating documents for examiner review.

Change Date

III.iv.3.A.8.a.  Importance of Claims Folder Review

References:  For more information on

• sending the claims folder in connection with a VA examination or opinion, see VAOPGCPREC 20-1995
• examinations requiring claims folder review, see M21-1, Part III, Subpart iv, 3.A.8.b, and
• requesting examiner review of the claims folder, see M21-1, Part III, Subpart iv, 3.A.8.c.

III.iv.3.A.8.b.  Examinations Requiring Claims Folder Review

• SC under 38 CFR 3.317
• cold injury residuals
• former prisoner of war (FPOW) protocol
• Gulf War general medical
• medical opinions, including etiology opinions in hearing loss and tinnitus claims
• mental health exams
• traumatic brain injury
• BVA remands
• 1151 Claims
• ACE
• environmental hazards in Iraq, Afghanistan, and other military installations, and
• IDES claims.

• requesting medical opinions, see M21-1, Part III, Subpart iv, 3.A.7
• handling examinations in claims for SC for PTSD, see M21-1, Part III, Subpart iv, 4.O.5
• requesting examinations in claims for SC under 38 CFR 3.317, see M21-1, Part IV, Subpart ii, 1.E.2
• ordering initial FPOW protocol examinations, see M21-1, Part III, Subpart iv, 3.A.4.c, and
• examinations based on ACE, see M21-1, Part III, Subpart iv, 3.A.4, and
• maintenance of eFolders, see M21-1, Part III, Subpart ii, 4.G.2.

III.iv.3.A.8.c.Requesting Examiner Review of the Claims Folder

III.iv.3.A.8.d. Requirement to Identify Relevant Evidence for the Examiner’s Review

• paper claims folder is tabbed, or
• eFolder is either bookmarked or annotated following the standardized procedures outlined in M21-1, Part III, Subpart iv, 3.A.8.e and f.

• timing of the duty to obtain an examination or opinion, see M21-1, Part I, 1.C.3.k
• the definition of relevant records, see M21-1, Part I, 1.C.4.a
• review of evidence to support examination requests in connection with claims for
  • direct SC, see M21-1, Part I, 1.C.3.d-f
  • secondary SC, see M21-1, Part I, 1.C.3.g
  • presumptive SC, see M21-1, Part I, 1.C.3.h, and
  • increase, see M21-1, Part I, 1.C.3.i
• procedures for identifying medical opinion evidence in the ERB tool, seeM21-1, Part III, Subpart iv, 3.A.7.d
• bookmarking and annotating documents in the eFolder, see M21-1, Part III, Subpart ii, 4.G.2.n and o, and
• categories of examinations for which the ACE process is prohibited, seeM21-1, Part III, Subpart iv, 3.A.4.b.

III.iv.3.A.8.e.  Bookmarking Documents for Examiner Review

III.iv.3.A.8.f.  Annotating Documents for Examiner Review

Introduction

• steps to requesting an examination in CAPRI, and
• completing a CAPRI examination request.

Change Date

III.iv.3.A.9.a. Steps to Requesting an Examination in CAPRI

III.iv.3.A.9.b.Completing a CAPRI Examination Request

• The examination location selected should be the appropriate facility identified using the guidance in M21-1, Part III, Subpart iv, 3.A.2.a–c.
• Under LIST OF EXAMS, select all appropriate DBQs.  Do not check DBQs for specific body systems if requesting a general medical examination unless the claim also requires the performance of one or more specialist examination(s) discussed in M21-1, Part III, Subpart iv, 3.A.6.a.
• Under the CLAIM TYPE field, select the relevant claim type.  Only one selection can be made.
• Under the SPECIAL CONSIDERATIONS field, select any priority processing reason(s) that applies, including
  • AGE OF CLAIM
  • FDC
  • HOMELESS
  • NOT APPLICABLE
  • POW, and/or
  • TERMINAL.
• For the LAST RATING EXAM DATE field, the default entry is N/A.  However, where there was a prior examination pertinent to the examination being entered, delete N/A and enter the date of the pertinent prior examination.
• In REMARKS
  • transfer all text generated by the ERB tool (to include, as applicable, the date of receipt of an ITF and/or other information manually entered in the ADDITIONAL EXAM REMARKS field of the ERB)
  • do not use manual, regulation, or code citations
  • avoid using acronyms or VBA jargon
  • if the examinee is not the Veteran, indicate the examinee’s relationship to the Veteran along with the Veteran’s name and VA claim number, and
  • if the examinee is rated incompetent, note that fact.

III.iv.3.A.10.a.  Entering an Examination Scheduling Request

• Requests for VHA examinations must still be entered in CAPRI.
• As is required with all automated tools, users must ensure that all VBMS system-generated language is legally and procedurally adequate before finalizing an examination scheduling request.  This includes ensuring that the SPECIAL INSTRUCTIONS field is completed so as to include information needed by the examiner, but not automatically generated.
• Report any
  • corrected information needed by submitting a trouble ticket, or
  • additional questions or concerns via e-mail toVAVBAWAS/CO/Contract Examination Inquiries.

Note:  VBMS examination scheduling request submission and acceptance will automate the creation of one tracked item for each contention identified in the request.  Manual entry of tracked items, as is directed in M21-1, Part III, Subpart iv, 3.A.9.a, for examination requests submitted through CAPRI, is not required for scheduling requests submitted through VBMS.

• types of requests requiring supplemental language from the ERB-S tool, see M21-1, Part III, Subpart iv, 3.A.10.b
• examination suspense dates, see M21-1, Part III, Subpart iv, 3.C.1.a
• contract examination exclusion reasons, see M21-1, Part III, Subpart iv, 3.A.1.j, and
• tracked item suspense and automation relative to examination management, see the VBMS User Guide.

III.iv.3.A.10.b. Types of Requests Requiring Supplemental Language from the ERB-S Tool

• entering an examination scheduling request, see
  • M21-1, Part III, Subpart iv, 3.A.10.a, and
  • the VBMS User Guide, and
• the ERB-S tool, see M21-1, Part III, Subpart iv, 3.A.2.f.

III.iv.3.A.10.c.  Definition:  Request for Clarification

• M21-1, Part III, Subpart iv, 3.A.10.d, and
• the VBMS User Guide.

III.iv.3.A.10.d. Responding to a Request for Clarification

• M21-1, Part III, Subpart iv, 3.A.10.c, and
• the VBMS User Guide.