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M21-1, Part III, Subpart v, Chapter 7, Section A – Eligibility for Hospital, Nursing Home, Domiciliary, and Medical Care

Overview

In This Section
This section contains the following topics:
Topic
Topic Name
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3
4
5
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7
8
9
10
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1.  Determining Eligibility for Medical Care

Introduction
This topic contains information on determining eligibility for medical care, including

Change Date
August 20, 2018

III.v.7.A.1.a.Methods of Information Exchange Between VBA and VHA
Requests for information and reports exchanged between the Veterans Benefits Administration (VBA) and the Veterans Health Administration (VHA) may be provided through
Requests for information from the medical facilities to the regional offices (ROs) may be necessary when the
  • Veteran is not entered into the AMIE/CAPRI system as a patient
  • medical facility is unable to access the Veteran’s corporate record, or
  • medical facility cannot ascertain required information from its inquiry into the Veteran’s corporate record.
This chapter relates primarily to the use of VA Form 10-7131 when CAPRI or other forms of communication, such as telephone contact, are not used for exchange of information.
Reference:  For information on CAPRI, see the CAPRI User Guide.

III.v.7.A.1.b.Determination of Eligibility for Medical Treatment
When a Veteran applies for medical treatment, the medical facility determines the Veteran’s eligibility and enrollment category for hospital, nursing home, domiciliary, medical, and dental care.  However, in certain cases such as those described in this section, the medical facility may require information from the RO in order to make a determination regarding eligibility for care.

III.v.7.A.1.c.Regulations Governing Eligibility for Medical Treatment
The table below lists regulations governing a Veteran’s eligibility for hospital, nursing home, domiciliary, medical, and dental care.
Type of Care
Governing Regulation(s)
Hospital, nursing home or domiciliary care
Outpatient treatment
Outpatient dental treatment

III.v.7.A.1.d.Types of Requests Sent on VA Form 10-7131
Refer to the table below for information on
  • the types of requests that may be sent on VA Form 10-7131, and
  • where to find more information on the particular type of request.
Upon receipt of VA Form 10-7131which involves a request that …
See …
requires claims folder review only
requires action by the authorization activity
requires action by the rating activity
pertains to eligibility for outpatient medical benefits under 38 U.S.C. 1710
pertains to requests for aid and attendance (A&A) and housebound medical benefits provided under 38 U.S.C. 1712(d)
pertains to medications for A&A cases in which income is excessive under 38 U.S.C. 1712(d)
pertains to treatment for a positive tuberculin reaction
pertains to Veterans treated with nasopharyngeal radium irradiation (NRI) under 38 U.S.C. 1720E
requires a determination of service connection (SC) for purposes of 38 U.S.C. 109(c) for the Polish and Czechoslovakian Armed Forces
 
Reference:  For more information on information exchange between ROs and medical facilities, see M21-1, Part III, Subpart v, 6.A.

III.v.7.A.1.e.  Types of Requests Sent on VA Form 20-0986 
VHA-initiated requests for medical benefits for former service members discharged under other-than-honorable (OTH) conditions are sent on VA Form 20-0986.  The form was released in January 2018.
Important:
Reference:  For more information on VHA-initiated requests for medical benefits when there is an OTH discharge, see M21-1, Part III, Subpart v, 7.A.7.

2.  Requests Requiring Claims Folder Review Only

Introduction
This topic contains information on processing requests for information received from medical facilities that require claims folder review only, including

Change Date
June 1, 2017

III.v.7.A.2.a.Receipt of VA Form 10-7131
The medical facility will check the specific boxes in Part I of VA Form 10-7131 to indicate the information required.

III.v.7.A.2.b.Processing  Requests Requiring  Claims Folder Review Only
When a request for information received on VA Form 10-7131 only requires review of the claims folder, follow the steps in the table below to respond to the medical facility with the requested information.
Step
Action
1
For each item requested in Part I, respond by entering the requested information in Part II of VA Form 10-7131.
Note:  All information may be legibly handwritten.
2
Mark any non-applicable items as N/A.
3
If information about monetary benefits is requested, and the Veteran receives military retired pay (MRP), complete Part II, Items 5 and 5A (Retirement Pay-By Whom Paid), to show the amount and source of the MRP.
Example:  $121–Army
4
Make an appropriate entry in the Remarks section to advise the VHA  facility of any of the following conditions which affect eligibility for hospitalization or treatment:
  • the Veteran has no period of honorable service
  • the Veteran has forfeited rights to benefits, or
  • the Veteran’s only service was in the Commonwealth Army of the Philippines, Special Philippine Scouts, or recognized Guerrilla Service.
Note:  If the Veteran’s only service was in the Commonwealth Army of the Philippines, Special Philippine Scouts, or recognized guerrilla service,
  • medical care is restricted to care provided by the Philippine government, or
  • the Department of Veterans Affairs (VA) may furnish hospital and nursing home care and medical services for treatment of service-connected (SC) disabilities only if the Veteran resides in the US.
5
Upon completion of the requested claims folder review,
  • return the original form to the medical facility
  • file the duplicate form in the claims folder, or upload a copy of the form into the Veteran’s electronic claims folder (eFolder), if one is present, and
  • clear an end product (EP) 400.

3.  Requests Requiring Action by the Authorization Activity

Introduction
This topic contains information on requests received from VHA facilities that require action by the authorization activity, including

Change Date
August 20, 2018

III.v.7.A.3.a.Requests Requiring an Administrative Decision
Requests involving authorization action generally require an administrative decision so that the originating VHA facility can determine health care eligibility when the
  • Veteran has an OTH discharge, or
  • evidence shows circumstances which require a line-of-duty (LOD) determination.
References:  For more information on

III.v.7.A.3.b.Processing Requests Requiring  Action by the Authorization Activity
Follow the steps in the table below when processing a VHA facility’s request that requires authorization action.
Step
Action
1
Complete any required development.
2
Prepare a formal administrative decision for the claims folder to determine
  • COD, or
  • LOD.
3
Complete Part II of VA Form 10-7131 with the requested information.
Exception:  VHA-initiated requests for medical benefits for former service members discharged under OTH conditions are sent on VA Form 20-0986.  In those cases, complete Parts IV and V of the form with the requested information.
4
  • Return the form via e-mail to the originating VHA facility using the e-mail address noted on the form, and
  • upload a copy of the completed form to the appropriate eFolder.
 
References:  For more information on

4.  Requests Requiring Action by the Rating Activity

Introduction
This topic contains information on requests from VHA facilities that require action by the rating activity, including

Change Date
March 11, 2019

III.v.7.A.4.a.Request for a Determination of SC
A VHA facility may request that an RO make a determination on the issue of SC for a particular condition for treatment purposes only.  This request may be received on VA Form 10-7131.
A copy of VA Form 10-10m, Medical Certificate, along with any other medical evidence available, will routinely be attached to the VA Form 10-7131.
A request for a determination of SC for active psychosis under 38 U.S.C. 1702 is an example of a request received from the medical facility on VA Form 10-7131.
 
Reference:  For more information on SC for psychosis under 38 U.S.C. 1702, see M21-1, Part IX, Subpart ii, 2.5.

III.v.7.A.4.b.Processing Requests Requiring Action by the Rating Activity
When a VHA facility request requires the rating activity to determine eligibility for SC for treatment purposes, follow the steps in the table below.
Step
Action
1
Is a rating decision for the condition already of record?
  • If yes, process the request as a request requiring claims folder review only as outlined in M21-1, Part III, Subpart v, 7.A.2.
  • If no, proceed to the next step.
2
Request that the claimant submit an application and refer to the table below to determine the appropriate subsequent action.
If …
Then …
an application is received within 30 days
  • send Section 5103notice to the claimant, if required
  • perform the necessary development, and
  • upon completion of development, proceed to the next step.
an application is not received within 30 days
  • notify the claimant that VA cannot consider SC without an application
  • return VA Form 10-7131to the originator, and
  • take no further action.
 
Important:  Do not generate a rating decision for the purpose of medical care eligibility in the absence of contentions from the Veteran.  VA must make an effort to obtain contentions by requesting an application from the Veteran.
Note:  Ensure that the request for an application informs the Veteran of the option of submitting a claim electronically.
Reference:  For more information on determining whether the issuance of Section 5103 notice is necessary, see M21-1, Part I, 1.B.1.d.
3
Refer the case to the rating activity.
4
When the rating decision is completed,
5
Return VA Form 10-7131 to the originator.
6
Promulgate the rating and send notification to the claimant.
 
References:  For more information on

5.  Requests for Outpatient Medical Benefits

Introduction

 This topic contains information on requests for outpatient medical benefits including

Change Date

 March 11, 2019

III.v.7.A.5.a.Eligibility for Outpatient Medical Services
Veterans who are enrolled in the VA healthcare system are eligible for outpatient medical services as defined in 38 CFR 17.38.
Veterans are assigned to one of eight enrollment priority groups at the time of enrollment. The priority group designation determines whether a co-payment will be required for outpatient services.

III.v.7.A.5.b.Eligibility Based on the Level of Disability
A Veteran with a single SC disability or a combination of disabilities that render him/her at least 50-percent disabled is
  • assigned to Priority Group 1, and
  • eligible for outpatient treatment for all disabilities with no co-payment requirement.
Note:  This includes a disability rating of a 50 or 100 percent under 38 CFR 4.28.

III.v.7.A.5.c.Providing Notification of Eligibility to the Veteran

 Following the initial processing of a rating establishing the Veteran’s level of disability, send the Veteran

  • a notice of eligibility, and
  • instructions for applying for treatment.

III.v.7.A.5.d.Processing Eligibility Requests

 When a VHA facility submits VA Form 10-7131 requesting information for eligibility of a Veteran under 38 U.S.C. 1710, complete the Remarks section of Part II by listing any and all SC and non-service-connected (NSC) disabilities and their assigned evaluations.

6.  Eligibility for Medical Treatment Tentatively Approved on Prima Facie Evidence

Introduction

 This topic contains information on making a tentative determination of eligibility for medical treatment based on prima facie evidence, including

Change Date

 July 21, 2015

III.v.7.A.6.a.Requirements for Determining Prima Facie Eligibility

 VHA facilities are authorized to determine prima facie eligibility upon which treatment may be initially authorized if

  • the Veteran was discharged or released with an honorable or general discharge after active service of
    • six or more months, if the enlistment date was prior to September 8, 1980, or
    • 24 or more months, if the enlistment date was September 8, 1980, or later.
  • application is made within six months from the date of discharge or release, and
  • the application of sound medical judgment warrants a tentative conclusion that the condition originated in, or was aggravated during, service.

III.v.7.A.6.b.Notifying the SOJ of an Initial Determination of Prima Facie Eligibility

 If treatment based on prima facie eligibility is initially authorized by VHA, then VHA

  • prepares a VA Form 10-7131 and annotates the form to show Medical care being authorized for [condition] on prima facie evidence of eligibility, and
  • forwards the completed form along with a copy of the VA examination, hospital report, or outpatient treatment report, as applicable, to the station of jurisdiction (SOJ).

III.v.7.A.6.c.Processing VA Form 10-7131
Follow the steps in the table below upon receipt of a VA Form 10-7131 communicating authorization of treatment for certain conditions based on prima facie eligibility.
 
Step
Action
1
Perform necessary development for service treatment records (STRs).
2
Refer the case to the rating activity for determination of SC for the condition(s) at issue.
3
Return the completed VA Form 10-7131 by following guidance in M21-1, Part III, Subpart v, 7.A.4.b.

7.  VHA-Initiated Requests for Medical Benefits for Former Service Members Discharged Under OTH Conditions

Introduction

 This topic contains information on requests for medical benefits for former service members discharged under OTH conditions, including

Change Date

 March 11, 2019

III.v.7.A.7.a.Requirements for Eligibility for Health Care
Health care benefits are generally extended to Veterans who meet the minimum active duty service requirements and were discharged or released under conditions other than dishonorable.
Medical facilities may request information from ROs when a COD determination is required for health care eligibility purposes.

III.v.7.A.7.b.  Initiation of VA Form 20-0986 by a VHA Facility
Upon receipt of an application for treatment from a former service member with an OTH discharge, the VHA facility initiates a VA Form 20-0986 advising the SOJ that an eligibility determination is needed.

III.v.7.A.7.c.  EP Control Over Eligibility Determination Requests
Use an EP 290 – Character of Discharge to control any incoming VHA request for an eligibility determination regarding COD.
Important:  If VHA’s request contains the language Mental Health Initiative (MHI) – Eligibility Determination Needed.  Please determine Chapter 17 entitlement,
  • ensure that the Emergency Care corporate flash has been appended to the former service member’s record, and
  • follow the procedural instructions found in M21-1, Part III, Subpart v, 7.A.7.e.
Notes:
  • If an application for disability compensation is received after an EP 290 has been established to control such a request,
    • separately establish the appropriate rating EP, using the date of receipt of the claim for disability compensation as the date of claim
    • add character of discharge as a contention, and
    • add the Character of Discharge special issue indicator to the contention.
  • If a VHA request is received while a rating EP is pending, and no COD determination has been made,
    • separately establish an EP 290 – Character of Discharge, and
    • add
      • character of discharge as a contention to the rating EP
      • the Character of Discharge special issue indicator to the contention, and
      • any tracked items for the COD determination, previously controlled solely under the rating EP, to the newly established EP 290.

III.v.7.A.7.d. Actions to Take Upon Receipt of an Eligibility Determination Request
When a VHA facility initiates a request for an eligibility determination regarding COD, follow the steps in the table below.
Exception:  If the eligibility determination request pertains to a former service member’s potential access to emergency mental health care, follow processing instructions in M21-1, Part III, Subpart v, 7.A.7.e.
Step
Action
1

Does review of the claims folder indicate that the RO has previously prepared a COD determination or a decision on eligibility for benefits under 38 U.S.C. Chapter 17?

  • If yes, proceed to Step 4.
  • If no, proceed to the next step.
2
Accomplish any and all development necessary to render an administrative decision in the matter of COD, including all available service department records (STRs, personnel records, and records of proceedings pertaining to the discharge).
Reference:  For more information on collecting information on the facts and circumstances surrounding discharge, see M21-1, Part III, Subpart v, 1.B.1.g.
3
Refer the case for preparation of an administrative decision.
4
Based on the outcome of the administrative decision,
5
Return VA Form 20-0986 to the originator, attaching a copy of the administrative decision.
6
Use the Letter Creator tool (or equivalent language in Personal Computer Generated Letters) to create a decision notice communicating the outcome of the administrative decision (unless such notification was previously provided) in accordance with M21-1, Part III, Subpart v, 1.B.1.i and 4.b.
7
Prepare a record-purpose award to clear the EP 290 – Character of Dischargeestablished to control the eligibility determination request.
8
Is a rating EP based on a claim for compensation benefits concurrently pending?
  • If yes, proceed to the next step.
  • If no,
    • take no further action, and
    • disregard the remaining steps in this table.
9
Use the table below to determine the next action.
If the COD determination deems the former service member’s service …
Then …
honorable for VA purposes
  • accomplish any and all normal development necessary to ready the case for rating disposition
  • refer the case for preparation of a rating decision addressing SC for specific conditions, and
  • proceed to the next step.
  • accomplish any and all development (to include requesting any medical opinions warranted) necessary to ready the case for rating disposition
  • refer the case for preparation of a rating decision addressing SC for treatment purposes for specified conditions, and
  • proceed to the next step.
  • due to a statutory bar to VA benefits under an offense specified in 38 CFR 3.12(c), or
  • eligible to neither SC compensation benefits nor health care benefits under 38 U.S.C. Chapter 17
  • clear the rating EP, and
  • disregard the remaining step in this table.
10
Process the rating decision rendered in response to Step 9 by
  • preparing a corresponding decision notice for the claimant
  • completing Part V of the VA Form 20-0986, and
  • returning VA Form 20-0986 to the originator.
 
References:  For more information on

III.v.7.A.7.e.  Actions Specific to Special Eligibility Determination Requests Involving Access to Emergency Mental Health Care
When a VHA facility initiates a request for an eligibility determination regarding COD, and the request contains the MHI language referenced in M21-1, Part III, Subpart v, 7.A.7.c, consider it sought in support of affording the former service member access to emergency mental health care, and prioritize action accordingly.
Note:  Application of the Emergency Care corporate flash mandated in M21-1, Part III, Subpart v, 7.A.7.c prompts National Work Queue reassignment to one of several designated processing stations.  Eligibility determination requests involving access to emergency mental health care are centrally processed by the Nashville and Winston-Salem ROs.
Follow the steps in the table below to respond to an eligibility determination request of this type.
Step
Action
1
  • Review the claims folder for a previously-prepared COD determination or decision on eligibility for benefits under 38 U.S.C. Chapter 17, and
  • accomplish any and all development necessary to render such a determination, as needed.
Reference:  For more information on development required for COD determinations, see M21-1, Part III, Subpart v, 1.B.1.
2
Reference:  For more information on providing notice of COD determinations’ outcomes toVA and non-VA entities, see M21-1, Part III, Subpart v, 1.B.1.j.
3
Use the table below to determine the next action.
If the former service member’s COD was deemed …
Then …
honorable for VA purposes
  • prepare a record-purpose award to clear the pending EP 290
  • remove the Emergency Care corporate flash, and continue processing the case from Step 8 of M21-1, Part III, Subpart v, 7.A.7.d.
dishonorable for VA purposes without eligibility to health care benefits under38 U.S.C. Chapter 17 (for reasons such as a statutory bar identified in 38 CFR 3.12(c))
  • prepare a record-purpose award to clear the pending EP 290
  • remove the Emergency Care corporate flash, and
  • disregard the remaining steps in this table.
dishonorable for VA purposes (for reasons such as a regulatory bar identified in 38 CFR 3.12(d)) but eligible to health care benefits under 38 U.S.C. Chapter 17
  • prepare a record-purpose award, continuing the EP 290 at authorization
  • remove the Character of Dischargespecial issue indicator
  • add the Emergency Care – CH17 Determination special issue indicator, and
  • proceed to the next step.
Important:  Unlike other VHA-initiated eligibility determination requests, those involving access to emergency mental health care must be construed as free-standing claims for SC for treatment purposes for any mental health condition(s) for which the Veteran is receiving treatment.
4
Because the request from VHA is received on a VA Form 20-0986 and not a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, ensure that Section 5103 notice requirements have been satisfied.
Accomplish any and all development necessary to ready the case for a rating decision (the development that would be required for SC under a typical rating EP) concerning the former service member’s entitlement to SC for treatment purposes for his/her mental health condition.
 
Note:  The development referenced above may involve the
  • acquisition of specified medical treatment records, and/or
  • ordering of any medical opinions warranted under M21-1, Part I, 1.C.3.b.
5
Prepare a rating decision addressing SC for the specified conditions for treatment purposes.
6
  • Process the rating decision prepared in Step 5, and
  • prepare a corresponding decision notice for the claimant.
7
  • Notify the originating VHA facility of all disabilities individually deemed SC or NSC for treatment purposes under 38 U.S.C. Chapter 17 by
    • completing Part V of the VA Form 20-0986, and
    • returning the form to the originating VHA facility
  • clear the pending EP 290, and
  • remove the Emergency Care corporate flash.
 
Note:  If a former service member in need of emergency mental health care submits a completed application claiming disability compensation for the underlying mental condition(s) before the issue of COD is resolved, any decision concerning SC for treatment purposes for the mental condition(s) will be decided under the pending EP 290.

8.  Requests for A&A and Housebound Medical Benefits

Introduction

 This topic contains information on requests for A&A and housebound medical benefits, including

Change Date

 April 12, 2007

III.v.7.A.8.a.Eligibility for Medical Services Under 38 U.S.C. 1712 (d)

 Under 38 U.S.C. 1712(d), Veterans receiving additional compensation or increased pension for A&A or housebound benefits are entitled to medical services, including

  • outpatient treatment
  • drugs, and
  • medicines.

III.v.7.A.8.b.Providing Notification of Eligibility to Veterans

 Notify a Veteran of medical care eligibility and application information when A&A or housebound benefits are awarded.  The information is provided on VA Form 21-8764, Disability Compensation Award Attachment, or VA Form 21-8768, Disability Pension Award Attachment.

III.v.7.A.8.c.Processing Eligibility Requests
Follow the steps in the table below when an eligibility request is received for medical services under 38 U.S.C 1712(d).
Step Action
1
Complete VA Form 10-7131 to show entitlement.
Note:  A future examination diary control has no effect on entitlement.
2
Complete the Remarks section of Part II of VA Form 10-7131 to show the following, as appropriate:
Veteran receiving [additional compensation/increased pension] by reason of being [in need of regular A&A/permanently housebound].

9.  Eligibility for Outpatient Medications for A&A Cases in Which Income Is Excessive

Introduction

 This topic contains information on eligibility for outpatient medications for A&A cases in which income is excessive, including

Change Date

 April 12, 2007

III.v.7.A.9.a.Income Limitation for Eligibility for Medications

 Per 38 U.S.C. 1712(d), VA continues to furnish outpatient medications to Veterans entitled to A&A, including those reduced under 38 CFR 3.552(b)(1), whose income exceeds the applicable limit by no more than $1,000.

III.v.7.A.9.b.Cases Involving the Termination of Pension Awards

 If a pension award to a Veteran entitled to A&A (code 1 or 2) is terminated because of excess income, message code 652, A&A Term—[Year] Income Over Limit by $_____, is issued for routing to the pension management center.

III.v.7.A.9.c.Processing Message Code 652
To process message code 652, follow the steps in the table below.
Step
Action
1
Review the claims folder to
  • verify that the Veteran is entitled to A&A, and
  • determine the amount by which income exceeded the maximum annual limit.
2
Annotate VA Form 20-6560, Notice of Benefit Payment Transaction, with entry of the amount over the income limit in the message legend space “$______”.
3
Date and sign the form.
4
Send the form to the requesting medical facility.
5
Annotate the claims folder to show the income information furnished to the medical facility.

III.v.7.A.9.d.Establishing Continued Entitlement to Medications
Establish continued entitlement to outpatient medications annually in those pension cases in which the current year income did not exceed the limit by more than $1,000.
Individual requests from the medical facility for income information for the next calendar year are received on VA Form 10-7131 during the last three months of the current year.

III.v.7.A.9.e.Requesting Income Information From the Veteran
Check the claims folder to determine if there is current data sufficient to permit furnishing income information for the next year.
If the claims folder does not already contain sufficient income data for the next year,
  • request that the Veteran complete the appropriate Eligibility Verification Report form, and
  • in the transmittal letter, indicate the reason for the request and state that the completed form should be returned within 30 days.

III.v.7.A.9.f.Completing the Remarks Section of VA Form 10-7131
Upon receipt of the desired information, or at the end of 30 days, enter the response in the Remarks, section, Part II, of VA Form 10-7131.
Use the table below to determine what to enter into Remarks when income information is received or not received from the Veteran.
If income information is …
Then …
  • received, and
  • the Veteran is entitled to A&A benefits, except as to income
indicate the amount by which income for the next year will exceed the applicable maximum income limit.
  • received, and
  • the Veteran is entitled to resumption of pension, including A&A allowance
not received
  • annotate VA Form 10-7131 to indicate that no reply was received from the Veteran, and
  • do not take follow-up action.

10.  Medical Treatment for Veterans Showing a Positive Tuberculin Reaction

Introduction

 This topic contains information on medical treatment for Veterans showing a positive tuberculin reaction, including

Change Date

 April 12, 2007

III.v.7.A.10.a.Chemotherapy Program Adopted by the Service Departments
Individuals who receive tuberculin tests sometimes show a change from negative to positive without any other evidence of a tuberculosis infection.
The military service departments have adopted a program of chemotherapy for personnel who had a negative tuberculin test on entrance into service, but who were found to have converted to positive during service.

III.v.7.A.10.b.Policy on Chemotherapy Treatments
Chemotherapy prescribed for personnel testing positive for tuberculin reaction is to be continued over a 12-month period to reduce the possibility of subsequently acquiring tuberculosis.
 
Important:  A positive tuberculin reaction without any other evidence of a tuberculosis infection is not a disease or disability and is not a reason for discharge from service.

III.v.7.A.10.c.Chemotherapy for Discharged Personnel
At the request of the military service departments, VA medical facilities provide continued chemotherapy for the remainder of the 12-month period to discharged personnel who tested positive for tuberculosis during service.
After treatment, the medical facility forwards VA Form 10-7131 to the SOJ with the following legend:
 
Medical care being authorized for positive reaction to tuberculin test on basis of prima facie evidence of eligibility.

III.v.7.A.10.d.Processing VA Form 10-7131
Follow the steps in the table below when you receive VA Form 10-7131 is received for discharged personnel testing positive for tuberculosis.
Step
Action
1
Interpret VA Form 10-7131 to mean there is no disease or disability present.
2
Associate VA Form 10-7131 with the claims folder without any control.
Notes:
  • A final report of examination is submitted at the end of the 12-month treatment period.
  • When completing any VA Form 10-7131 subsequently received in which Service-Connected is checked in Part I, do not make any reference to SC for a positive tuberculin reaction.
Reference:  For more information on compensation claims based on a positive tuberculin reaction, see M21-1, Part IV, Subpart ii, 1.I.1.

11.  Eligibility Requirements for Veterans Treated With NRI

Introduction

 This topic contains information on eligibility requirements for Veterans treated with NRI under 38 U.S.C. 1720E, including

Change Date

 July 21, 2015

III.v.7.A.11.a.Definition: NRI

 Nasopharyngeal Radium Irradiation (NRI) is a technique developed in the 1920s that used radium to treat hearing loss caused by repeated ear infections.  This technique was also used for treating other conditions including

  • sinusitis
  • tonsillitis
  • asthma
  • bronchitis, and
  • repeated viral and bacterial infections.

III.v.7.A.11.b.Background on NRI Use in the Military

 Because NRI was effective in treating otitis media, military physicians used NRI to treat aerotitis media (barotrauma) in submariners, aviators, and divers due to enlarged tissue in the throat combined with rapid pressure changes.

III.v.7.A.11.c.Policy on Services Provided to Veterans
VA is authorized to provide Veterans with a medical examination, hospital care, medical services, and treatment for any cancers of the head or neck found to be associated with the Veteran’s receipt of NRI treatment during active service.
Reference:  For more information on NRI, see 38 U.S.C. 1720E.

III.v.7.A.11.d.Eligibility Requirements for Medical Care

 To be eligible for VA medical care under this provision of law, the Veteran must have

  • documentation of NRI treatment in active military, naval, or air service
  • served as an aviator in the active military, naval, or air service before the end of the Korean Conflict, or
  • undergone submarine training during active naval service before January 1, 1965.

Notes:

  • Eligible Veterans may receive this care whether or not they are enrolled for VA healthcare.
  • No co-payment is required for medical care associated with NRI treatment.

III.v.7.A.11.e.Types of  Examinations  and Care Offered
Veterans with head or neck complaints or who are concerned about the possible adverse effects of their NRI treatments will be offered the opportunity to receive an Ionizing Radiation Registry examination.
Examination by an ear, nose, and throat specialist and additional studies, such as biopsies, will be performed if clinically indicated.

III.v.7.A.11.f.Provision of Other Services for Veterans Receiving Medical Care Due to NRI Treatment

 Provision of other services for Veterans receiving medical care due to NRI treatment is dependent on eligibility, as determined by the medical facility.

III.v.7.A.11.g.Verification of Eligibility

 If the VA medical facility cannot verify eligibility for treatment on the basis of the information of record, a request for verification of eligibility may be sent to the SOJ.

III.v.7.A.11.h.Processing the Eligibility Request

 When a request for verification for NRI treatment is received,

  • review the Veteran’s records to determine whether one or more of the eligibility criteria stated in M21-1, Part III, Subpart v, 7.A.11.d have been met, and
  • return VA Form 10-7131 or the 7131 AMIE/CAPRI request with Remarks in Part II annotated to state Eligibility to medical treatment under 38 U.S.C. 1720E [is/is not] established.

12.  Eligibility Requests for Polish and Czechoslovakian Armed Forces

Introduction

 This topic contains information on eligibility requests for the Polish and Czechoslovakian Armed Forces, including

Change Date

 July 21, 2015

III.v.7.A.12.a.Statutory Basis for Eligibility
Public Law (PL) 94-491 amended 38 U.S.C. 109 by establishing eligibility for medical services for certain members of the Polish and Czechoslovakian Armed Forces who served during World War I or II.
Reference:  For more information, see 38 U.S.C. 109(c).

III.v.7.A.12.b.Rating Jurisdiction

 The Wilmington RO has sole rating jurisdiction for Veterans of the Polish and Czechoslovakian Armed Forces.

III.v.7.A.12.c.Information Forwarded When Rating Action Is Required

 If the claim is identified as a PL 94-491 case and rating action is required, the Wilmington VA medical center, Medical Administration Service, is responsible for developing the claim and will refer the following items to the Wilmington RO:

  • VA Form 10-7131 indicating the specific condition for which SC for treatment purposes is claimed
  • a copy of the certification of service establishing dates of qualifying service during World War I or II
  • records of treatment of the disability during service, and
  • current medical evidence relating to the disability.
Note:  In these cases, no VA claim number is assigned.
Reference:  For more information on rating disabilities under the provisions of 38 U.S.C. 109(c), see M21-1, Part IX, Subpart ii, 2.10.

III.v.7.A.12.d.Establishing Controls

 Maintain temporary control pending completion of rating action by using an alphabetical holding file under the claimant’s last name.
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03-10-16_Key-Changes_M21-1III_v_7_SecA.docx May 16, 2019 68 KB
03-10-16_Key-Changes_M21-1III_v_7_SecA-1.docx May 16, 2019 68 KB
Historical_M21-1III_v_7_SecA_8-20-18.docx May 16, 2019 87 KB
Change-July-21-2015-Transmittal-Sheet-M21-1III_v_7_SecA_TS.docx May 16, 2019 43 KB
11-17-16_Key-Changes_M21-1III_v_7_SecA.docx May 16, 2019 79 KB
11-30-17_Key-Changes_M21-1III_v_7_SecA.docx May 16, 2019 97 KB
3-11-19_Key-Changes_M21-1III_v_7_SecA.docx May 16, 2019 71 KB
in Chapter 7 Eligibility for Department of Veterans Affairs (VA) Medical and Dental Treatment, Part III General Claims Process, Subpart v General Authorization Issues and Claimant Notification
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