Overview
In This Section |
This section contains the following topics:
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1. Obtaining Examination Reports
Introduction |
This topic contains information about obtaining reports, including
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Change Date |
February 19, 2019 |
III.iv.3.D.1.b. Contract Examination Reports |
Examination reports completed by Department of Veterans Affairs (VA) contract examiners are automatically uploaded into VBMS.
Use the table below to obtain from appropriate vendor portals any outstanding contract examination reports that are not immediately associated with the electronic claims folder (eFolder).
Important:
Note: Contract examination reports obtained through the means described above must be
Reference: For more information on VBMS Exam Management functionality, see the VBMS User Guide.
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2. Examination Report Requirements
Introduction |
This topic contains information about reviewing examination reports, including
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Change Date |
February 19, 2019 |
III.iv.3.D.2.b. Examiner Qualifications and Signature Requirements |
VA medical facilities (or the medical examination contractor) are responsible for ensuring that examiners are adequately qualified.
RO employees are not expected to routinely scrutinize or question the credentials of clinical personnel to determine the acceptability of their reports, unless there is contradictory evidence of record. However, examination reports (and DBQs, if they are to be used in lieu of examination) must include a valid signature by the certifying professional.
Use the table below to determine what certification elements are required to authenticate an examination provider’s signature and qualifications.
Notes:
References: For more information on
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III.iv.3.D.2.c. Telehealth and Telemental Health Examinations |
When VHA elects to conduct a videoconference examination (ortelehealth/telemental health examination) in lieu of an in-person examination, assess the report for sufficiency under the same standards applicable to in-person examinations.
Important:
Reference: For more information on telehealth and telemental health examinations, see the Office of Disability and Medical Assessment (DMA) Expansion of Telehealth for Compensation and Pension (C&P) Examinations Fact Sheet.
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III.iv.3.D.2.d. DBQs Completed by VA or Non-VA Health Care Providers |
Review DBQs which are completed by VA or non-VA health care providers to ensure
Note: DBQs completed by a licensed health care provider, to include a nurse practitioner or physician’s assistant, are acceptable for VA examinations.
References: For more information on
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III.iv.3.D.2.e. Insufficient DBQs Completed by Non-VA Providers |
Use the table below to determine what action should be taken after receiving a DBQ that has been
Note: No action to develop an insufficient DBQ need be taken if the facts of the case would not otherwise necessitate providing an examination and/or opinion.
Reference: For more information on determining when an examination or medical opinion is necessary, see M21-1, Part I, 1.C.3.b.
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III.iv.3.D.2.f. Authenticity of DBQs |
In general, as with other items of evidence, DBQs from treatment providers should be taken at face value.
However, all DBQs completed by treatment providers are subject to validation to confirm the authenticity of the information provided.
DBQs released for public use inform the provider
Where a review of the DBQ raises questions of authenticity or improper alteration, determine whether additional development is necessary. This may include
Informal contact with the Office of Inspector General or a fraud referral may also be appropriate.
References: For more information on
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III.iv.3.D.2.g.DBQs Completed by Veterans Who Are Physicians/
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VA cannot summarily discount otherwise competent medical evidence from a Veteran who is a physician or health care provider. DBQ reports completed by these individuals will be reviewed under the same criteria for reviewing DBQs submitted by a third-party health care provider.
In effect, VA claims adjudicators must subject the evidence of record to some degree of scrutiny to determine its probative worth. It is improper in VA practice to “exclude” evidence. Decision makers must weigh the probative value of the evidence and discuss its probative value in the decision narrative.
Note: Exercise the same weighing of probative value for internal-use DBQs that are completed by an external non-VA provider.
Important: Ensure the Disability Benefits Questionnaire (DBQ) – Veteran Provided DOCUMENT TYPE under VBMS UNSOLICITED EVIDENCE tab has been updated for DBQs submitted from non-VA providers.
References: For more information on
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III.iv.3.D.2.h. Qualification Requirements of Examiners – Initial Mental Disorder Examinations |
The following credentialed mental health professionals are qualified to performinitial C&P mental disorder examinations:
Note: “Close supervision” means that the supervising psychiatrist or psychologist met with the Veteran and conferred with the examining mental health professional in providing the diagnosis and the final assessment. The supervising psychiatrist or psychologist must co-sign the examination report.
Important: For a claim for service connection (SC) for posttraumatic stress disorder (PTSD) based upon a stressor related to the Veteran’s fear of hostile military or terrorist activity, 38 CFR 3.304(f)(3) directs that the examination must be conducted by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted.
Reference: For more information on the qualifications of examiners for specific examinations, to include initial mental disorders examinations, PTSD, and eating disorders, see the DBQ Switchboard.
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III.iv.3.D.2.i. Qualification Requirements of Examiners – Review or Increased Evaluation Mental Disorder Examinations |
The following credentialed mental health professionals are qualified to perform C&P mental disorder review examinations or examinations in claims for increased evaluations of service-connected (SC) mental disorders:
Reference: For more information on the qualifications of examiners for review examinations for PTSD, see the PTSD Disability Benefits Questionnaire in theDBQ Switchboard.
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III.iv.3.D.2.j.Qualification Requirements of Examiners – TBI Examinations |
The initial diagnosis of TBI must be made by one of the following specialists:
Note: A generalist clinician who has successfully completed the Disability Examination Management Office TBI training module may conduct a TBI examination, if a TBI diagnosis is of record and was established by one of the aforementioned specialty providers.
Reference: For more information on qualifications of examiners for TBI examinations, see the TBI Disability Benefits Questionnaire in the DBQ Switchboard.
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III.iv.3.D.2.k.Qualification Requirements of Examiners –Hearing Loss and Tinnitus |
Hearing loss examinations must be completed by a state-licensed audiologist. A hearing loss examination is needed for an initial examination for tinnitus.
If only a tinnitus examination is being requested, the examination may be conducted by either an audiologist or non-audiologist clinician, if a hearing loss examination is of record.
References: For more information on
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III.iv.3.D.2.l. Requirements for Examination Reports |
VA examinations are to be conducted using DBQs which are disease- and condition-specific, organized as a documentation tool to provide the precise medical evidence needed to rate specific disabilities. The examiner is
Note: The report must have a definite and unambiguous description of the disability for each complaint or claimed condition.
Common features of DBQs include
Additional sections may be found on some DBQs, depending on the specialty involved.
Reference: For more information on DBQs, see the DBQ Switchboard.
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III.iv.3.D.2.m.Requirements for ACE Examination Reports |
When an examination provider uses acceptable clinical evidence (ACE) in lieu of conducting an in-person examination, review the report for sufficiency.
The report must
Reference: For more information on ACE examinations, see M21-1, Part III, Subpart iv, 3.A.4.
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III.iv.3.D.2.n. Evaluating Disability Diagnoses |
The precise cause of a disability is often difficult to determine. It is important that
The table below describes various examination scenarios and what is required for a sufficient diagnosis.
Reference: For more information on handling examinations insufficient for rating purposes, see M21-1, Part III, Subpart iv, 3.D.3.
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III.iv.3.D.2.o. Questions About Competency and/or Validity of Examinations |
Duly consider concerns raised by the claimant or his/her recognized representative about a completed examination or opinion. Communications raising concerns may take the form of (but are not necessarily limited to)
The mere fact that such a communication is received does not mean that the examination is insufficient or in need of clarification, or that there is a further duty to assist to obtain records or another examination. However, consideration must be given to whether one or more of those remedies is appropriate.
The table below provides guidance on interpreting communications from claimants or a representative raising concerns about examinations and what action to take, as applicable.
Note: VA’s C&P claim adjudication system does not have a procedure for completion of interrogatories by VA personnel. Interrogatories are written questions that, in some court proceedings, must be answered under oath. If the claimant or representative submits a communication characterized as an interrogatory
References: For more information on
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III.iv.3.D.2.r. Examiner Statements that an Opinion Would be Speculative |
Pay careful attention to any conclusion by the examiner that an opinion could not be provided without resorting to mere speculation (or any similar language to that effect).
VA may only accept a medical examiner’s conclusion that an opinion would be speculative if
The medical opinion may be insufficient for rating purposes if an examiner’s conclusion
In such instances, seek clarification of the conclusion.
Note: If the examiner specifically states that a medical opinion cannot be provided unless specific evidence is made available, VA’s duty to assist requires that VA determine whether that evidence may be reasonably obtained. If so, VA is to make efforts to obtain it and then seek an additional medical opinion which considers the relevant information.
Reference: For more information on speculative opinions, see
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3. Handling Examinations Reports That Are Insufficient for Rating Purposes
Introduction |
This topic contains information about returning insufficient examination reports, including
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Change Date |
February 19, 2019 |
III.iv.3.D.3.a.Insufficient Examination Reports |
A VA examination report submitted to the rating activity must be as complete as possible.
Any missing, required information on the report makes the examination report insufficient for rating purposes.The following are examples of deficiencies that would render an examination report insufficient:
Note: If the rating activity determines that a necessary examination was canceled without a valid reason, it must submit a new examination request to the examining facility and specify why the previous cancellation was inappropriate.
Example: An examination requested in connection with a claim for a knee condition was not completed because “the claimed condition was not documented and diagnosed in the service treatment records on examiner review.” If the rating activity determines that such examination is needed, the existing report or cancellation notice should be returned to the examining facility as insufficient for rating purposes.
Important: There are instances where missing information in an examination report does not make the examination itself insufficient. However, claims processors must seek and obtain the missing information via communication with and clarification by the examiner, as discussed in M21-1, Part III, Subpart iv, 3.D.3.c, before issuing a final decision on the underlying claim.
References: For more information on
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III.iv.3.D.3.b.Handling Insufficient Examination Reports That Were Erroneously Requested |
In Barr v. Nicholson, 21 Vet.App. 303 (2007), Court of Appeals for Veterans Claims (CAVC) held that if VA provides an examination when developing a claim for SC, even if not statutorily obligated to do so,
Exception: The above requirement for adequacy does not apply to examination reports initiated by VHA that do not
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III.iv.3.D.3.d. Resolving Inconsistencies |
Resolve any inconsistency or conflicting findings of various medical examiners by requesting a medical opinion by a different examiner.
References: For more information on requesting
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III.iv.3.D.3.e. Returning Examination Reports Requested Through CAPRI |
Refer to the table below to determine how to return an insufficient or inadequate examination report to the appropriate provider when the examination was originally requested through CAPRI.
Important:
Notes:
References: For more information on
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III.iv.3.D.3.f. Returning Examination Reports Requested Through VBMS |
Refer to the table below to determine how to return an insufficient or inadequate examination report to the appropriate provider when the examination was originally requested through VBMS.
Important: Avoid using language that can be construed as adversarial when returning reports for clarification. Use the term insufficient for rating purposesrather than inadequate examination.
Notes:
References: For more information on
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4. Reviewing Examination Reports for Rating Criteria
Introduction |
This topic contains information about examination considerations specific to certain disabilities and body systems, including
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Change Date |
February 19, 2019 |
III.iv.3.D.4.a. Bruxism Examination Report Review |
Bruxism is defined as excessive grinding of the teeth and/or excessive clenching of the jaw.
Bruxism may not be rated as a stand-alone SC disability. However, it may be considered on a secondary basis as a symptom of a SC disability, such as an anxiety disorder, temporomandibular disorder (TMD), or another disability for rating purposes.
If an examination report diagnoses bruxism, then the examiner has to provide the etiology of bruxism.
Reference: For information on processing dental claims, see M21-1, Part III, Subpart v, 7.C.
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III.iv.3.D.4.b. Eye Examination Report Review |
When a visual field defect is perceived, examiners must perform any necessary visual field testing using either
If the examination was not performed using the proper testing method, then the examination report should be returned as insufficient. An examination sufficient for rating purposes must include, at minimum,
Important: Irrespective of the eye condition being examined, no visual field testing is required if the examiner indicates that the Veteran does not suffer a visual field defect. The absence of visual field testing results does not, in these instances, render an examination report insufficient for rating purposes.
Reference: For more information about eye conditions, see
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III.iv.3.D.4.c. Headache Examination Report Review |
A neurological headache examination report will be considered insufficient if it does not indicate the frequency of prostrating headaches and whether the headaches are migraine-type or non-migraine type.
Reference: For more information on rating migraines, see
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III.iv.3.D.4.d. Hearing Loss and Tinnitus Examination Report Review |
A hearing loss and tinnitus examination report may be considered insufficient if an opinion was requested by the RO and is not provided in the report.
Unusual circumstances may arise during the examination, requiring the examiner to
Reference: For more information on requesting audiometric examinations and medical opinions, see M21-1, Part III, Subpart iv, 4.D.1.d.
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III.iv.3.D.4.e. Mental Health Examination Report Review |
Mental health examinations can be complex when there are psychological symptoms existing simultaneously with and usually independently of another medical condition, such as PTSD and TBI symptoms of memory loss.
An examination report may be insufficient if
Reference: For more information on considering a change in the diagnosis of a psychiatric disorder, see M21-1, Part III, Subpart iv, 4.O.1.c.
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III.iv.3.D.4.f. Heart Conditions Examination Report Review for METs |
The metabolic equivalents of task (METs) score for heart conditions can be provided as an estimate, as indicated on the DBQs. If the Veteran has co-morbid conditions that prevent the examiner from performing METs testing or providing an interview-based METs estimate, then the
Reference: For information on rating heart conditions, see M21-1, Part III, Subpart iv, 4.G.2.
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III.iv.3.D.4.g. Musculoskeletal Examination Report Review for ROM |
In order to address CAVC’s interpretation of VA’s regulations in DeLuca andMitchell, musculoskeletal joint examination reports must address ROM criteria for repetitive motion and flare-ups.
Following the initial assessment of ROM, the examiner must perform repetitive-use testing to the extent permitted by the disability under evaluation. After the initial measurement, the examiner must reassess ROM after three repetitions and report the post-test measurements.
The examination report is insufficient if the examiner does not
In order to address CAVC’s holdings in Corriea and ensure adequacy for rating purposes, musculoskeletal examination reports must also reflect testing of
Musculoskeletal examination reports containing self-evident contradictory findings, conclusions, and/or terminology will also be rendered insufficient or require additional clarification. Examples of such contradictory examination features include, but are not limited to, the following:
References: For more information on
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III.iv.3.D.4.h. Musculoskeletal Examination Report Review for Functional Loss |
The clinician conducting a musculoskeletal examination must address additional functional limitation or LOM during flare-ups or following repeated use over time, based on the Veteran’s history and the examiner’s clinical judgment.
The examination report must address whether the functional ability of a joint is significantly limited during flare-ups or when the joint is used repeatedly over a period of time due to
If such opinion is not feasible, then the examiner must state so and provide an explanation as to why the opinion cannot be rendered.
Example: John Smith reports severe knee pain with repeated use over time when walking back and forth to the store several times a day. During those flare-ups, the capacity for knee flexion is demonstrated/reported to be 0-110 degrees.
References: For more information on musculoskeletal examination report review for
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III.iv.3.D.4.i. Musculoskeletal Examination Report Review for X-rays |
During review of musculoskeletal examination reports, check to ensure that x-rays were obtained when necessary.
A diagnosis of arthritis must be confirmed by x-ray or other radiographic testing before SC) may be established.
Where there is a claim of non-specific joint pain in a joint or multiple joints, x-rays will not be provided prior to the Veteran being seen by the examiner.
However, when arthritis is claimed or diagnosed, the examination and/or medical evidence of record must include x-rays of the joint at issue. If the examination does not include x-rays, and none are otherwise available for consideration, then return the examination report as insufficient.
Note: Once arthritic changes are shown in a joint, no further x-rays will ever be required for that joint to support a diagnosis of arthritis.
References: For more information on musculoskeletal examination report review for
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III.iv.3.D.4.j. Nerves Examination Report Review |
Examiners must, to the extent possible, identify the nerve that best correlates to the area affected even if the condition is a spinal cord nerve condition.
This information will allow the rating decision to address the functional impairment of the area affected.
Reference: For more information on diseases of the peripheral nerves, see
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III.iv.3.D.4.k. Respiratory Examination Report Review for PFTs |
Pulmonary function tests (PFTs) are required for most respiratory conditions unless
Obtaining and reporting the PFT is only half of the requirement. The other half of the requirement is for the examiner to interpret the PFT in relation to the claimed condition.
References: For more information on
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III.iv.3.D.4.l. Skin and Scars Examination Report Review |
Use the table below to ensure a skin or scar examination report is not considered insufficient for rating purposes.
Notes:
Reference: For more information on rating skin conditions and scars, see
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III.iv.3.D.4.m. Sleep Disorders Examination Review |
Sleep apnea must be diagnosed with a sleep study. Review the sleep study to ensure the condition is interpreted in relationship to the claimed condition.
If there is an SC condition that is co-morbid to the sleep apnea that requires a PFT, like asthma, ensure that such testing was completed.
Sleep disturbances including insomnia may be claimed as a secondary condition, but not inclusively, to
Notes:
References: For more information on
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III.iv.3.D.4.n. TMD Examination Report Review |
There is no need to return a TMD examination report to VHA simply because a dentist did not perform the examination. TMD is musculoskeletal in nature.
Important: As part of the musculoskeletal requirements, the TMD DBQ requires the examiner to address
References: For more information about
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III.iv.3.D.4.o. TBI Examination Report Review |
Ensure the initial TBI diagnosis is provided by a qualified examiner.
The examiner must address
A mental health evaluation alone is not sufficient in addressing TBI. A TBI examination completed by a medical clinician, with input from a mental health examiner, needs to be completed when attributable signs and symptoms co-exist.
Objective evidence and neuropsychiatric testing may be required when cognitive impairment symptoms are identified. Some examples of cognitive impairment symptomology include
References: For more information on
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5. Taking Rating Action on RFE Results
Introduction |
This topic contains information about taking action on the results of RFEs, including when an RFE
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Change Date |
February 19, 2019 |
III.iv.3.D.5.a. When an RFE Shows Worsening Symptomatology |
Use the table below to determine the rating action to take if results of a routine future examination (RFE) demonstrate worsening symptomatology.
Note: Under the circumstances described above, do not raise the issue of entitlement to a temporary total rating under 38 CFR 4.29 or 4.30 unless the evidence of record supports a grant of such benefits.
References: For more information on
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III.iv.3.D.5.b. When an RFE Demonstrates Development of Additional Residual or Secondary Disabilities |
Use the table below to determine the rating action to take if results of an RFE demonstrate that a primary SC disability has progressed to involve the development of one or more additional residual, complications, or secondary disabilities.
Reference: For more information on actions to take when an RFE shows worsening symptomatology, see M21-1, Part III, Subpart iv, 3.D.5.a.
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