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M21-1, Part III, Subpart iv, Chapter 3, Section F – Examinations in Special Situations

Overview


In This Section 

This section contains the following topics:

1.  A&A and Housebound Examinations


Introduction

This topic contains information about A&A and housebound examinations, including

Change Date

June 21, 2018

III.iv.3.F.1.a.  Purpose of an A&A and Housebound Examination

The aid and attendance (A&A) and housebound examination is designed to
  • pinpoint findings relevant to A&A determinations under 38 CFR 3.351 and38 CFR 3.352, and
  • provide a basis for determining if the housebound benefit may be paid if the need for A&A is not shown.

III.iv.3.F.1.b.  When an A&A and Housebound Examination May Be Useful

It may be useful to request an A&A and housebound examination before a final determination is made, especially if the evidence of record demonstrates a reasonable probability of entitlement to A&A or housebound benefits but is not sufficient to allow the benefit.
Note:  As provided in 38 CFR 3.326, an examination is not required and should not be pursued if the evidentiary record is otherwise sufficient to independently support entitlement to A&A or housebound benefits.

III.iv.3.F.1.c.  Requesting an A&A and Housebound Examination

Use the table below when requesting an A&A and housebound examination.
Note:  A disability benefits questionnaire (DBQ) does not exist at this time for A&A and housebound examinations.
If the examination is being requested via use of the …
Then …
Compensation and Pension Record Interchange (CAPRI)
  • select AID AND ATTENDANCE OR HOUSEBOUND EXAMINATION from the LIST OF EXAMS menu, and
  • ensure any relevant information for the examiner is placed in the COMMENTS field.
Veterans Benefits Management System (VBMS)
  • associate the examination scheduling request with the A&A contention, ensuring that its classification type isSpecial Monthly Compensation – Aid and Attendance/Housebound
  • select Aid and attendance from the IS SPECIALTY LANGUAGE NEEDED? field’s associated drop-down menu
  • enter the disabilities upon which the claim is based in the NAME OF DISABILITIES field
  • ensure any other relevant information for the examiner is placed in the SUPPORTING SPECIALTY LANGUAGE INFORMATION or SPECIAL INSTRUCTIONS field, and
  • select DBQ A&A Worksheet – VA Form 21-2680 from the AVAILABLE DBQs menu.
References:  For more information on

III.iv.3.F.1.d.  Locally Devised Checklists

Regional offices (ROs) are not authorized to create local checklists for A&A and/or housebound examinations.
Checklists created and submitted by individual treatment providers should be evaluated as any other item of evidence.  However, Yes or No blocks do not provide sufficient descriptive information to assess the extent of a claimant’s incapacitation.

2.  Special Issue Claims and Other Types of Examination Requests


Introduction

This topic contains information about other types of examination requests, including

Change Date

February 19, 2019

III.iv.3.F.2.a.  Examinations of Non-Veteran Claimants and Beneficiaries

As the facts of an individual case demand, the rating activity may schedule examinations of non-Veteran claimants and beneficiaries
  • only after approval by the Veterans Service Center Manager (VSCM) or Pension Management Center Manager (PMCM), or
  • to determine if a
    • claimant is entitled to A&A or housebound benefits
    • Chapter 18 birth defect diagnosis exists
    • claimant was insane at the time he/she caused the death of the Veteran
    • dependent child or child claimant is helpless and/or incompetent, and/or
    • beneficiary is competent to handle his/her funds.
References:  For more information on

III.iv.3.F.2.b.  Hospital Observation

To properly visualize and evaluate complex disability issues, the rating activity may request a period of hospitalization for observation and examination.

III.iv.3.F.2.c.  Field Examinations

Request a field examination when it is not possible, through the routine examination process, to
  • determine the competency of the beneficiary
  • assess employment and social adjustment, or
  • substantiate items of evidence regarding the existence of disease or injury prior to enlistment.
Reference:  For more information on requests for field examinations, see M21-1, Part III, Subpart vi, 8.8.

III.iv.3.F.2.d.  Examinations of Incarcerated Veterans

An incarcerated Veteran is entitled to a Department of Veterans Affairs (VA) compensation examination as part of the duty to assist.
When examination of an incarcerated Veteran is required, the RO, Veterans Benefits Administration (VBA) contract examination provider, and/or local Veterans Health Administration (VHA) Medical Examination Coordinator must confer with prison authorities to determine whether the Veteran should be
  • escorted to a VA medical facility for examination by VHA personnel, or
  • examined at the prison by
    • VBA contract examination providers
    • VHA personnel, or
    • fee-basis providers contracted by VHA.
Important:
  • Because some State laws restrict the movement of and access to prison inmates, the above options may not be possible.  In such cases, documentation of substantial efforts to schedule and conduct the examination must be added to the claims folder.
  • ROs must include the following information, to the extent that it is known, in examination requests for incarcerated Veterans:
    • name of the correctional facility
    • location of the correctional facility
    • circumstances of confinement (e.g. nature/type of conviction, level of institutional security, etc.), and
    • whether the Veteran is considered violent.
  • ROs must document all efforts made to schedule an examination, including identifying and requesting the assistance of the appropriate prison officials.
  • VHA compensation clinics and VBA contract examination vendors are required to provide documentation that they have
    • made substantial attempts to schedule and conduct the examination, and
    • exhausted all possible avenues for obtaining access to the incarcerated Veteran for the examination.
  • If the examination provider has exhausted examination efforts to no avail, treat a Veteran’s inability to attend a necessary examination (claim-relatedor review) by reason of incarceration as the equivalent of a failure to report, and take appropriate action in accordance with M21-1, Part I, 1.C.3.m.
Note:  Request any examination(s) needed in support of an incarcerated Veteran’s claim for individual unemployability (IU) benefits, as discussed in M21-1, Part IV, Subpart ii, 2.F.2.c and d, even though there may be no award of such benefits while the Veteran is incarcerated.
References:  For more information on

III.iv.3.F.2.e.  Board Examinations

There should be at least two physicians, preferably three, on “board examinations,” and at least one (but preferably all) should be a recognized specialist in the particular field involved.
The rating activity has the authority to request board examinations to
  • reconcile differing diagnoses, or
  • resolve particularly complex issues concerning
    • awards of special monthly compensation, or
    • entitlement to specially adapted housing.

III.iv.3.F.2.f.  Reexaminations by a Different Examiner

The rating activity may request that the claimant be reexamined by another medical examiner if compelling reasons exist.
To request a reexamination
  • prepare another examination request
  • annotate it to show that reexamination is necessary
  • identify any specific information needed in the examination report, and
  • include the name and the facility of the medical examiner who conducted the prior examination.

Reference:  For more information on preparing examination requests, see M21-1, Part III, Subpart iv, 3.A.


III.iv.3.F.2.g.  Homeless Veteran Examination Requests

ROs must expedite the processing of all claims submitted by Veterans who are

  • homeless, or
  • at immediate risk of homelessness.
Depending upon the Examination Request Routing Assistant tool’s recommendations, use the appropriate system to request these examinations, and ensure that the following comment (or its near equivalent) is included in the body of the examination request:
Claim for a homeless or at imminent risk of homelessness Veteran.  Expeditious processing is requested. 
Reference:  For more information on priority processing of claims from homeless Veterans, see M21-1, Part III, Subpart ii, 1.D.2.

3.  FPOW Protocol Examinations


Introduction

This topic contains information about FPOW protocol examinations, including

Change Date

June 21, 2018

III.iv.3.F.3.a.  Reviewing FPOW Claims

Review all claims from former prisoners of war (FPOWs), including original claims, supplemental claims, and claims for an increased evaluation, to determine if the
  • Veteran’s record confirms FPOW status, and
  • Veteran was examined under the FPOW protocol.
References:  For more information on

III.iv.3.F.3.b.  Considerations When Requesting an FPOW Protocol Examination

If the FPOW was not examined under the FPOW protocol, request an examination utilizing the Former Prisoner of War (POW) Protocol Disability Benefits Questionnaire, unless it
  • would be inadvisable in light of the Veteran’s medical condition, or
  • is specifically declined by the Veteran or his/her representative.
Note:  Monetary benefits to an FPOW will not be denied unless the claimant has been offered a complete physical examination conducted at a VA hospital or outpatient clinic.
Reference:  For more information on examination requirements, see 38 CFR 3.326.

III.iv.3.F.3.c.  When to Order Initial FPOW Protocol Examinations

Order an initial Former Prisoner of War (POW) Protocol Disability Benefits Questionnaire even if medical evidence to support the claim is not of record but FPOW status is established.
Note:  The FPOW Protocol DBQ is restricted to internal use only and must be completed by a VHA examiner.  Contract examiners are not authorized to complete the DBQ.

III.iv.3.F.3.d.  How to Order Initial FPOW Protocol Examinations

In preparing a request for an initial FPOW protocol examination,
  • utilize the Exam Request Builder (ERB) tool to build the examination request
  • select POW in the SPECIAL CONSIDERATION(S) box in CAPRI
  • clearly note that an examination under the FPOW protocol is required, and
  • request an examination of all claimed and noted disabilities, as well as all other conditions characteristically associated with confinement as an FPOW.
Notes:
  • The examiner is required to review the claims folder for all FPOW examinations.
  • The Veteran is required to complete VA Form 10-0048, Former POW Medical History, before the examination.  VHA mails the form to the Veteran with instructions to complete the form and bring the form on the date of examination.
  • The forms completed by the Veteran and the completed DBQ will be returned to the requesting RO.
References:  For more information on

4.  Pre-Discharge Examinations


Introduction

This topic contains information about pre-discharge examinations, including

Change Date

March 12, 2018

III.iv.3.F.4.a.  Who Is Eligible for Pre-Discharge Examination

Pre-Discharge claim submission is available to service members with no more than 180 days remaining until discharge at select military installations that contain VA intake sites.
References:  For more information on

III.iv.3.F.4.b.  What the SHA Examination Covers

The Separation Health Assessment (SHA) is a single separation examination which supports the VA disability compensation process and the Department of Defense (DoD) separation/retirement process.  It includes the Separation History and Physical Examination Program (SHPE).
Service members who do not file claims with VA will receive an SHA/SHPE at their local military treatment facility in connection with their transition processing.  The SHA/SHPE captures the service member’s current health information in a way that is easily accessible by both DoD and VA.
The SHA process provides service members with an improved general medical examination, which includes an audiogram, any specialty exams deemed necessary, and a full lab analysis, using VA’s examination protocols.  The service member completes and provides the DD Form 2807-1, Report of Medical History, to the examiner.  The examiners will complete their designated section of the DD Form 2807-1, and the completed form will be added to the service member’s service treatment records (STRs).
Note:  The service member may elect to upload the completed DD Form 2807-1into eBenefits with the pre-discharge claim(s) application instead of bringing the form to the SHA examination.

III.iv.3.F.4.c.  General Medical Examinations and the SHA
Effective October 2013, all eligible Benefits Delivery at Discharge (BDD) claimants receive an SHA in lieu of a general medical examination.  Those claimants who file pre-separation claims that are excluded from the BDD program, however, will continue to require a general medical examination and should not be examined under the SHA protocol.
The SHA DBQ is an available selection for use in connection with BDD claims at most facilities. Select the SHA DBQ if it is available at the requested examination facility and add the following comment:  BDD claim.
If the SHA DBQ is not an available system selection for use in connection with a BDD claim, select the general medical DBQ and add the following statement to the comments:  BDD claim:  SHA DBQ is requested.
References:  For more information about

5.  Examinations of Pregnant Claimants


Introduction

This topic contains information about examinations for pregnant claimants, including


Change Date

February 19, 2019

III.iv.3.F.5.a.  General Information on Examinations for Pregnant Claimants

Many pregnant claimants submit claims for conditions that are either

  • directly related to pregnancy, or
  • acute and transitory and expected to resolve upon delivery.

Some physical examinations and routine tests required to accurately rate the disabilities identified in claims are complicated and not recommended for or normally performed on pregnant women since they may pose a significant health risk to the woman or baby.


III.iv.3.F.5.b.  Ancillary Conditions of Pregnancy

Some ancillary conditions common to pregnancy are

  • anemia
  • back pain
  • edema in the legs
  • gestational diabetes
  • hypertension
  • shortness of breath, and
  • urinary tract infections.

III.iv.3.F.5.c.  Tests Not Recommended for Pregnant Claimants

Tests and procedures that are not recommended for pregnant claimants include

  • x-rays
  • pulmonary function tests (PFTs), and
  • range of motion examinations.

Note:  When pregnancy is known, include in the examination request a comment indicating that the claimant is pregnant.


III.iv.3.F.5.d.  How Pregnancy Affects Participation in Pre-Discharge Programs

The station of jurisdiction (SOJ) processes and rates pre-discharge claims for pregnant service members locally.  Pregnant service members may file pre-discharge claims up to 180 days prior to separation/retirement; however, the claims are excluded from processing through the BDD program.
Since pregnancy prohibits certain diagnostic tests and procedures, the examiner may be unable to accurately assess the claimant’s medical condition.  This would preclude completion of the examination and the rating process until conclusion of the pregnancy.
Reference:  For more information on claim types or attributes that are excluded from the BDD program, see M21-1, Part III, Subpart i, 2.A.1.e.

III.iv.3.F.5.e.  Options for Processing Claims for Pregnant Claimants

There are three options for processing claims for pregnant claimants.  The receiving RO should determine, on an individual basis, which of the following actions is appropriate based on the claimed contentions:

  • defer the entire examination until conclusion of the pregnancy
  • rate the entire claim based on existing STRs and evidence of record, or
  • rate any claimed conditions that may be awarded based on existing STRs and evidence, and defer consideration of any additional disabilities that may not be examined until conclusion of the pregnancy.

Example:  Service connection for an amputated finger can be awarded based on STRs, but the other claimed issues require specific tests that are prohibited due to pregnancy and must be deferred until the pregnancy concludes and a full examination can be conducted.

Reference:  For more information on partial rating decisions and deferred issues, see M21-1, Part III, Subpart iv, 6.A.


6.  IMOs


Introduction

Change Date
 February 19, 2019

III.iv.3.F.6.a.  Definition:  IMO

An independent medical opinion (IMO), as discussed in 38 CFR 3.328, is
  • a type of advisory medical opinion that may be obtained from one or more recognized medical experts who are not VA employees, and
  • only warranted in connection with
    • claims of significant medical complexity and/or controversy, and/or
    • fulfillment of instructions contained in a remand order from the Board of Veterans Appeals (BVA).
Notes:
  • As discussed in M21-1, Part III, Subpart iv, 3.F.6.d, VA Central Office has the responsibility for deciding
    • if the IMO is warranted, and
    • what medical expert(s) to use.
  • Under 38 CFR 3.328, contract examiners who perform examinations during the usual claims process are considered hired in the service of VA, and therefore, are not appropriate medical experts for the purposes of providing an IMO.

III.iv.3.F.6.b.  Who May Initiate a Request for an IMO

A request for an IMO under 38 CFR 3.328, in conjunction with a pending claim, may be initiated by the
  • SOJ
  • claimant, or
  • claimant’s representative.

III.iv.3.F.6.c.  Submitting a Request for an IMO

Submit a request for an IMO
  • in writing
  • through the VSCM or PMCM, and
  • by stating, in detail,
    • the reasons why the opinion is necessary, and
    • the specific information or opinion required.

III.iv.3.F.6.d.  Processing Requests for an IMO

The table below describes how to process a request for an IMO under 38 CFR 3.328 and identifies the responsible parties.
Stage
Who is Responsible
Description
1
  • rating activity, or
  • service organization representative
Brings the request for an IMO to the attention of the VSCM or PMCM.
2
  • VSCM, or
  • PMCM
Decides whether the request has merit.
3
  • VSCM, or
  • PMCM
Does the request have merit?
  • If yes, refers the compensation request to Compensation Service (211) or the pension/survivor’s request to Pension and Fiduciary (P&F) Service for review.
  • If no, denies the request without the need for referral to Compensation Service or P&F Service.
Important:  This determination may only be contested as part of a legacy appeal or notice of disagreement (NOD) to BVA on the primary issue under consideration.
4
  • Compensation Service, or
  • P&F Service
Decides whether the request has merit.
5
  • Compensation Service, or
  • P&F Service
Does the request have merit?
  • If yes,
    • notifies the claimant that the request has been approved
    • obtains the opinion from the appropriate medical expert, and
    • sends a copy of the opinion when it is available.
  • If no, denies the request.
Important:  This determination may only be contested as part of a legacy appeal or NOD to BVA on the primary issue under consideration.
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