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M21-1, Part IV, Subpart ii, Chapter 1, Section E – Developing Claims Based on Service in Southwest Asia Under 38 CFR 3.317

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
Developing Claims for Service Connection (SC) of Brain Cancer Based on Southwest Asia Service

1.  Developing Claims Based on Southwest Asia Service


Introduction

This topic contains information on developing Southwest Asia claims, including


Change Date

March 14, 2019

IV.ii.1.E.1.a.  Action to Take When the Veteran Alleges Exposure to Environmental Hazards but Claims No Disability

A claim is not substantially complete if a Veteran alleges exposure to environmental hazards during service but does not claim service connection (SC) for a specific disability.  In cases such as these, follow the procedures for handling an incomplete application at M21-1, Part I, 1.B.1.g and h.
Important:  When a Veteran with Southwest Asia service files a claim for a sign or symptom of undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI), it must be processed as a substantially complete claim.
References:  For more information on

IV.ii.1.E.1.b.  Initial Development Action on a New Southwest Asia Service Claim

It is unnecessary to issue Section 5103 notice when a Veteran files a new claim for SC for a qualifying disability under 38 CFR 3.317 that resulted from service in Southwest Asia on a form that provides, or otherwise indicates he/she received, the notice, such as VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.
Note:  If a Veteran alleges joint and/or muscle pain without specifying which joint(s)/muscle(s) is affected
  • make an attempt to contact the Veteran by telephone to specify the joint(s) and/or area(s) affected, and
  • even if telephone contact is unsuccessful, proceed with all necessary claims development procedures, including requesting an examination, if needed to decide the claim.
References:  For more information on

IV.ii.1.E.1.c.Verifying Southwest Asia Service Using DD Form 214

Use the table below when reviewing the Veteran’s DD Form 214, Certificate of Release or Discharge from Active Duty, for verification of Southwest Asia service.
If the DD Form 214 shows …
Then consider …
  • service in Southwest Asia with exact dates listed in theRemarks section
  • Iraq Campaign Medal, or
  • Kuwait Liberation Medal
service in Southwest Asia verified.
Southwest Asia Service Medal
service in Southwest Asia potentially verified.
Important:  Review the DD Form 214and/or personnel records to ensure that this medal was not awarded solely for service in Israel, Egypt, Turkey, Syria, or Jordan (including the airspace above and the territorial waters) from January 17, 1991, through November 30, 1995.
  • Global War on Terrorism Service/Expeditionary Medal, or
  • Inherent Resolve Campaign Medal
  • service in Southwest Asia notverified, and
  • request service personnel records, if not already of record, for verification of Southwest Asia service.
Reference:  For more information on procedures for locating and obtaining personnel records, see
Afghanistan Campaign Medal
  • service in Afghanistan verified for the sole purpose of a claim for presumptive SC for infectious diseases listed under38 CFR 3.317(c), and
  • Southwest Asia service notverified for the purpose of compensation for undiagnosed illness or MUCMIs.
Reference:  For more information on locations considered as Southwest Asia theater of operations, see

IV.ii.1.E.1.d.  Requesting Service Department Records in a Southwest Asia Claim

In addition to service treatment records (STRs), request
  • clinical records, if the Veteran furnishes information on the application about specific inpatient treatment, and
  • service personnel records, if the dates of service in Southwest Asia during the Gulf War period that began on August 2, 1990, are not already of record.
Note:  Concurrently request clinical records, service personnel records, and STRs, if all are needed.
Reference:  For more information on requesting clinical records, service personnel records, and STRs, see M21-1, Part III, Subpart iii, 2.B.

IV.ii.1.E.1.e.  Requesting Medical Evidence in Claims Under 38 CFR 3.317

Request reports of all private and Department of Veterans Affairs (VA) medical treatment that is indicated by the Veteran, both during and after service, including records such as
  • statements or reports from
    • doctors
    • hospitals
    • laboratories
    • medical facilities, and
    • mental health clinics
  • x-rays, and
  • physical therapy records.
Note:  If the Veteran indicates that a Gulf War Registry Health examination has been conducted, request the examination report from the appropriate medical facility.
Reference:  For more information on determining whether an examination is necessary in a claim under 38 CFR 3.317, see M21-1, Part IV, Subpart ii, 1.E.2.

IV.ii.1.E.1.f.  Considering Whether to Clarify or Corroborate Lay Statements

Unless there is reason to doubt the credibility of a lay statement, do not develop to corroborate it.
References:  For more information on

2.  Examinations in Claims Based on Southwest Asia Service


Introduction

This topic contains information on examinations in claims based on Southwest Asia service, including


Change Date

March 14, 2019

IV.ii.1.E.2.a.  When an Examination Is Necessary in Southwest Asia Claims

When an examination is needed to decide the claim, 38 CFR 3.159(c)(4) provides that an examination must be requested in cases falling under 38 CFR 3.317 when there is
  • competent lay or medical evidence of a disease (or signs or symptoms of a disease) listed in 38 CFR 3.317 manifesting within the period specified in 38 CFR 3.317, namely
    • no later than December 31, 2021, for disability due to undiagnosed illness and MUCMIs, or
    • as provided in 38 CFR 3.317(c)(3)(i) for infectious diseases, and
  • service required by 38 CFR 3.317, which is either
    • qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2)or
    • qualifying service in Afghanistan (for the purpose of a claim under 38 CFR 3.317(c) only).
Examples:  For additional discussion and examples of when an examination is and is not necessary in Southwest Asia claims, see M21-1, Part IV, Subpart ii, 1.E.2.dl.
Important:
  • The Veteran does not have to identify a claimed disability as due to Gulf War service.  VA must broadly consider applicable legal avenues that may be available based on the facts – even if not specifically pleaded by the claimant.
  • The threshold for requiring an examination is low.  It is lower than the standard to prove entitlement to SC under 38 CFR 3.317, because the purpose is only to determine whether VA has a duty to assist in substantiating the claim.
References:  For more information on

IV.ii.1.E.2.b.When to Request a Gulf War General Medical Examination in a Southwest Asia Claim

Request a Gulf War general medical examination when the threshold for an examination is met as provided in M21-1, Part IV, Subpart ii, 1.E.2.a.  When an examination is needed for a claim under the provisions of 38 CFR 3.317, request
  • Gulf War General Medical Examination (Including Burn Pits) Disability Benefits Questionnaire (DBQ), and
  • any required specialist DBQs as defined in M21-1, Part III, Subpart iv, 3.A.1.h.
Exception:  Do not request a Gulf War general medical examination if one has been completed in response to a pending claim or a decision that has not yet become final per 38 CFR 3.160(d).  In these cases, only order the specialty DBQ specific to the claimed condition.
Example 1:  A claim is received for SC for irritable bowel syndrome (IBS) based on Southwest Asia service and hearing loss based on military acoustic trauma.  A Gulf War general medical examination is requested.  Since it requires a specialist, a hearing loss DBQ is also ordered.  SC for hearing loss is granted, but the claim for SC for IBS is denied.  A claim for SC for chronic fatigue syndrome (CFS) based on Southwest Asia service is received five months after the denial of SC for IBS.  The regional office (RO) determines an examination is needed to decide the CFS claim.
Analysis:  In this case, do not request a new Gulf War general medical examination since the decision on the previous claim is not yet final per 38 CFR 3.160(d).  Request the CFS DBQ only.
Example 2:  Same scenario as in Example 1, except the claim for SC for CFS is received 15 months after the denial of SC for IBS.  The RO determines an examination is needed to decide the CFS claim.
Analysis:  In this case, order the Gulf War general medical examination for the CFS claim since the decision on the previous claim is final per 38 CFR 3.160(d).
Note:  When requesting examinations in support of a Southwest Asia claim
  • send the claims folder to the examiner to review
  • insert the required language for the examination type as shown in M21-1, Part IV, Subpart ii, 1.E.2.c, and
  • do not prepare a separate medical opinion DBQ.  The Notice to Examiners in Southwest Asia Claims directs the examiner to provide the required medical opinion.

IV.ii.1.E.2.c.  Required Language in Examination Requests for Southwest Asia Claims

ROs must ensure that all examiners in Southwest Asia claims have access to the proper terminology and opinion language specific to these types of claims.  Consequently, ROs must follow the guidance in the table below to ensure examination requests for Southwest Asia claims contain the appropriate language for all examiner(s).
If requesting a …
Then in the examination request, include the …
Gulf War general medical examination only
Notice to Examiners in Southwest Asia Claimsfrom M21-1, Part IV, Subpart ii, 1.E.2.m.
  • Gulf War general medical examination, and
  • specialist examination(s)
Reference:  For more information on specialist examinations, see M21-1, Part III, Subpart iv, 3.A.1.h.
specialty DBQ only
Reference:  For more information on specialty examinations, see M21-1, Part III, Subpart iv, 3.A.1.g.

IV.ii.1.E.2.d.  Impact of Known Clinical Diagnoses on Whether an Examination Is Necessary for a Southwest Asia Claim

When a Veteran has sought treatment for claimed chronic signs and symptoms listed in 38 CFR 3.317, it is likely that the medical provider has rendered a diagnosis for those symptoms.  However, the existence of a clinical diagnosis with specific etiology, which may weigh against 38 CFR 3.317 entitlement, does not preclude the ordering of an examination unless all symptoms claimed by the Veteran are clearly attributable to the diagnosis.
If there is a question as to whether the claimed signs and symptoms are attributable to an established clinical diagnosis, and if the criteria specified in M21-1, Part IV, Subpart ii, 1.E.2.a have been met, an examination is necessary.
In such cases when an examination is warranted, the VA examiner’s workup must include an assessment of whether signs and symptoms represent a disease with a clear and specific etiology or whether they fall into a different disability pattern.
Reference:  For more information on when to order an examination, see M21-1, Part IV, Subpart ii, 1.E.2.el.

IV.ii.1.E.2.e.  Example:  Examination Is Necessary in Southwest Asia Claim With Known Clinical Diagnosis

Facts:  A Veteran with Southwest Asia service claims SC for “upper respiratory problems” and “sleep disturbance.”  A review of the medical evidence reveals various diagnoses over the last three years, to include asthma, sleep apnea, and seasonal allergies.  The Veteran indicates he has trouble sleeping, and experiences wheezing and shortness of breath when exerting himself.  He has received inhalers and other medications for his symptoms.  It is not clear if comprehensive clinical testing has been performed to support the diagnoses.
Result:  Although there is a potential that the Veteran’s claimed symptoms are attributable to a known diagnosis, a VA examination is warranted.  The different diagnoses of record raise questions about what condition is specifically producing the symptoms, and the evidence is not clear as to whether the appropriate testing was conducted to support the diagnoses.

IV.ii.1.E.2.f.  Example:  Examination Not Necessary in Southwest Asia Claim With Known Clinical Diagnosis

Facts:  A Veteran with Southwest Asia service claims SC for “sleep disturbance.”  STRs do not show any relevant treatment or diagnoses.  Private medical evidence reveals the Veteran awakes several times a night, snores loudly, and has episodes of breathing cessation during sleep.  A sleep study showing a diagnosis of obstructive sleep apnea was provided.  In the medical report, it was noted that the described symptoms were consistent with sleep apnea.
Result:  In this case, an examination is not warranted since it is clear that the sole cause of “sleep disturbance” is sleep apnea.  Further, sleep apnea is not a recognized qualifying, chronic disability under the provisions of 38 CFR 3.317.

IV.ii.1.E.2.g.  Example:  When an Examination Is Necessary in a Southwest Asia Claim

Facts:  A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2).  He files a claim for SC for fatigue and multiple-joint pain.  STRs do not show any relevant treatment or diagnoses.  Current medical records show complaints of regular fatigue and soreness in the knees, elbows, and wrists for the last year without any noted injury or other specific cause listed.  Assessments over the last year from the Veteran’s internist have included rule out arthritis, rule out bursitis, and likely overuse syndrome.
Result:  An examination must be ordered.  Although the Veteran did not specifically state that he was filing a “Gulf War” claim or mention 38 CFR 3.317, he has the required service for consideration of SC under 38 CFR 3.317.  There is also lay and medical evidence of chronic signs or symptoms that are listed as potential manifestations of undiagnosed illness or MUCMI in 38 CFR 3.317(b), and these signs and symptoms manifested within the period specified in 38 CFR 3.317.  The fact that there is the possibility that the symptoms could be attributable to a disability with a clear and specific etiology does not change the fact that an examination is necessary.

IV.ii.1.E.2.h.  Gulf War General Medical Examination Unnecessary in a Southwest Asia Claim When the Claim Is Substantiated

Do not order a Gulf War general medical examination when the evidence is adequate to substantiate the claim under 38 CFR 3.317 or on another basis (for example, 38 CFR 3.3033.3063.3073.3093.310) – even if the threshold for an examination as stated in M21-1, Part IV, Subpart ii, 1.E.2.a is met.
When there is a current diagnosis of a MUCMI from 38 CFR 3.317(a)(2)(i)(B)(1) to (3) (CFS, fibromyalgia, or any listed functional gastrointestinal disorder) an examination is not necessary unless workup is needed for the purpose of assigning a disability evaluation.
Important:  A specialist or specialty examination, whichever is appropriate based on the specific disability, is still required if the evidence is not fully sufficient to rate, including assignment of a disability evaluation.
Notes:
  • 38 CFR 3.159(c) provides that the duty to assist applies only when evidence is necessary to substantiate the claim.
  • 38 CFR 3.159(c)(4) provides that an examination or opinion is necessary only if the information and evidence of record is not sufficient to decide the claim.
  • 38 CFR 3.326(a) provides that an examination is authorized when there is a claim for disability compensation but the medical evidence accompanying the claim is not adequate for rating purposes.
Reference:  For more information on specialty and specialist examinations, seeM21-1, Part III, Subpart iv, 3.A.1.g and h.

IV.ii.1.E.2.i.  Example 1: Examination Is Unnecessary Because Southwest Asia Claim Is Substantiated

Facts:  A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2).  The claims folder contains a competent medical assessment of CFS.  The evidence shows that this developed to a compensable degree after service but before December 31, 2021.  The evidence of record contains enough information to assign an evaluation for CFS.
Result:  Do not request an examination.  The claim is substantiated under 38 CFR 3.317.  The evidence shows a claimant with service qualifying for consideration of38 CFR 3.317 has a MUCMI listed in the regulation that developed in the period specified in the regulation.  The evidence is sufficient to award SC and assign an evaluation.

IV.ii.1.E.2.j.  Example 2: Examination Is Unnecessary Because Southwest Asia Claim Is Substantiated

Facts:  A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2).  The claims folder shows chronic bilateral knee pain developing during Southwest Asia service without a specific injury.  The assessments in service were bilateral knee strain, rule out arthritis, and bilateral knee pain.  X-rays were negative.  The current medical evidence shows a complaint of bilateral knee pain and a diagnosis by a private doctor of bilateral knee strain.  The doctor has offered the opinion that the strain had its onset in service.  There is no superseding post-service injury.  The record contains enough information to assign an evaluation.
Result:  Do not request an examination.  Although there is a question as to whether this is truly a disability with a clear and specific etiology (a bilateral knee strain) or whether there is an undiagnosed illness manifested by multiple joint pain, the claim for SC is substantiated on a direct basis under 38 CFR 3.303.  The evidence is sufficient to award SC for bilateral knee strain and to assign an evaluation.

IV.ii.1.E.2.k.  Examination Unnecessary – No Potential 38 CFR 3.317 Entitlement

An examination is not necessary in a limited variety of cases where there is no potential entitlement under 38 CFR 3.317.
Examples:
  • Do not order an examination when a Veteran with service in Southwest Asia claims neurological symptoms manifesting within the period specified in 38 CFR 3.317 but there is a competent medical diagnosis of multiple sclerosis (MS) and competent medical evidence attributing the symptoms to MS.  MS is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained.  Also, the condition is typically diagnosed only after a neurological examination and hallmark tests such as magnetic resonance imaging (MRI) and cerebrospinal fluid testing.
  • Do not order an examination when a Veteran with service in Southwest Asia claims fatigue, neurological, skin or other listed symptoms manifesting within the period specified in 38 CFR 3.317 but there is a competent medical diagnosis of diabetes and competent medical evidence attributing the symptoms to diabetes.  Diabetes is listed in 38 CFR 3.317(a)(2)(ii) as a chronic multi-symptom illness of partially understood etiology and pathophysiology that cannot be considered medically unexplained.  Also, the condition is typically diagnosed only after clinical evaluation and hallmark testing such as blood glucose testing or hemoglobin A1C tests.
  • Do not request an examination when the claim is for a single joint injury – not an undiagnosed illness or medically explained multi-symptom illness –and the evidence shows
    • trauma to the joint in service or thereafter, and
    • a known clinical diagnosis such as traumatic arthritis or meniscal tear indicating an injury etiology.

Exception:  Obtain an examination where the criteria in M21-1 Part IV, Subpart ii, 1.E.2.a are otherwise met when there is

  • an equivocal or provisional diagnosis, such as “rule out MS” or “possible diabetes mellitus”
  • a diagnosis of MS or diabetes is questionable due to lack of workup, or
  • claimed symptoms are not clearly attributed to the clinical diagnosis.

Note:  It is possible in cases involving MS, diabetes, or specific joint injuries that although an examination based on Southwest Asia service is not indicated, the facts may support that an examination on another basis is necessary under 38 CFR 3.159(c)(4) to determine whether the condition had its onset in service or within another applicable presumptive period.


IV.ii.1.E.2.l.  Example:  Examination Unnecessary – No Potential 38 CFR 3.317 Entitlement

Facts:  A Veteran has qualifying service in the Southwest Asia theater of operations as defined in 38 CFR 3.317(e)(2).  The Veteran claims right wrist pain from an injury in service in Iraq in 2008 related to mechanic duties.  Service records are negative for any wrist injury, complaints or diagnosis.  Post-service records show complaints of wrist pain starting two years after service discharge in 2010.  Several of the earliest of those post service records note that the Veteran related a history of pain after a recent fall playing basketball.  The assessments include fall on an outstretched hand with possible wrist fracture, rule out traumatic arthritis and wrist strain.  X-rays were negative.
Result:  Do not request an examination.  The Veteran had qualifying Southwest Asia service and demonstrated chronic joint pain – a listed sign or symptom of undiagnosed illness or MUCMI – during the regulatory period specified in 38 CFR 3.317.  However, this was explicitly a claim for an injury and the facts show both a reported post-service injury and known clinical diagnoses indicative of injury etiology.  There is no potential entitlement under 38 CFR 3.317 or any other basis.  There is no potential for a MUCMI or undiagnosed illness based on the facts.

IV.ii.1.E.2.m.  Notice to Examiners in Southwest Asia Claims

Add the following Notice to Examiners in Southwest Asia Claims to examination requests as described in M21-1, Part IV, Subpart ii, 1.E.2.c:
Please examine this Veteran, who has service in Southwest Asia, for any chronic disability pattern.  Please review the claims folder as part of your evaluation and state, with your findings, that it was reviewed.  The Veteran has claimed a disability pattern related to [insert symptoms described by Veteran].
Please provide a medical statement explaining whether the Veteran’s disability pattern is:
(1) an undiagnosed illness
(2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology
(3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or
(4) a disease with a clear and specific etiology and diagnosis.
If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either (1) an undiagnosed illness; or (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, then no medical opinion or rationale is required as these conditions are presumed to be caused by service in the Southwest Asia theater of operations.
If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion, with supporting rationale, as to whether it is “at least as likely as not” that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia.

IV.ii.1.E.2.n.  Definitions for Examiners in Southwest Asia Claims

Add the following definition language to examination requests as described in M21-1, Part IV, Subpart ii, 1.E.2.c:
DEFINITIONS:  VA statutes and regulations provide for service connecting certain chronic disability patterns based on exposure to environmental hazards experienced during military service in Southwest Asia.  The environmental hazards may have included:  exposure to smoke and particles from oil well fires; exposure to pesticides and insecticides; exposure to indigenous infectious diseases; exposure to solvent and fuel fumes; ingestion of pyridostigmine bromide tablets, as a nerve gas antidote; the combined effect of multiple vaccines administered upon deployment; and inhalation of ultra fine-grain sand particles. In addition, there may have been exposure to smoke and particles from military installation “burn pit” fires that incinerated a wide range of toxic waste materials.
The chronic disability patterns associated with these Southwest Asia environmental hazards have two distinct outcomes.  One is referred to as “undiagnosed illnesses” and the other as “diagnosed medically unexplained chronic multi-symptom illnesses”. An undiagnosed illness is established when findings are present that cannot be attributed to a known, clearly defined diagnosis, after all likely diagnostic possibilities for such abnormalities have been ruled out.  Examples of medically unexplained chronic multi-symptom illnesses include, but are not limited to: (1) chronic fatigue syndrome, (2) fibromyalgia, and (3) functional gastrointestinal disorders.  Diseases of “partially explained etiology,” such as diabetes or multiple sclerosis, are not considered by VA to be in the category of medically unexplained chronic multi-symptom illnesses.
The following list of signs and symptoms may represent an “undiagnosed illness” or “diagnosed medically unexplained chronic multi-symptom illnessfor which a Gulf War Veteran may be presumptively service connected:
Fatigue
Signs or symptoms involving the skin
Headache
Muscle pain
Joint pain
Neurological signs and symptoms
Neuropsychological signs or symptoms
Upper or lower respiratory system signs or symptoms
Sleep disturbances
Gastrointestinal signs or symptoms
Cardiovascular signs or symptoms
Abnormal weight loss
Menstrual disorder

3.  Developing Claims for SC of Brain Cancer Based on Southwest Asia Service


Introduction


Change Date

March 14, 2019

IV.ii.1.E.3.a. General Development Principles for Claims for SC of Brain Cancer Based on Southwest Asia Service

Although there is no presumption of SC for brain cancer due to service in Southwest Asia, claims processors must develop these claims in accordance with the provisions of direct SC under 38 CFR 3.303 and the procedures contained in this topic.
Important:
  • If the Veteran is terminal, follow special handling procedures noted inM21-1, Part III, Subpart ii, 1.D.
  • Although based on the same definition of Southwest Asia theater of operations service, the presumptive SC provisions of 38 CFR 3.317 donot apply to brain cancer.
Reference:  For more information on considering direct SC for brain cancer, see M21-1, Part IV, Subpart ii, 2.D.1.r.

IV.ii.1.E.3.b. Procedures for Developing Claims for SC of Brain Cancer Based on Southwest Asia Service

Follow the procedures below when processing a claim for SC of brain cancer due to service in Southwest Asia.
Step
Action
1
Is there evidence in the military medical and personnel records to verify service in the Southwest Asia theater of operations during Gulf War I (spanning January 17, 1991, through April 11, 1991)?
  • If yes, proceed to next step.
  • If no, send the claim for a decision.
2
Is there credible medical evidence showing a diagnosis of brain cancer?
  • If yes, proceed to the next step.
  • If no, send the claim for a decision.
3
If evidence is not otherwise sufficient to decide the claim, request a medical or examination for brain cancer and any claimed residuals in accordance with the guidance in M21-1, Part IV, Subpart ii, 1.E.3.cand d.
Reference:  For more information on locations considered as Southwest Asia theater of operations, see

IV.ii.1.E.3.c. When to Request an Examination in Claims for SC of Brain Cancer

In the case of claims for brain cancer from Gulf War I Veterans, VA will request a medical examination or opinion when the claim
  • contains competent medical evidence of a diagnosis of brain cancer
  • establishes the Veteran served in the Southwest Asia theater of operations during Gulf War I, and
  • does not otherwise provide sufficient evidence to decide the claim.
Since there is no presumptive basis for granting SC, the medical examiners will determine, on a case-by-case basis, whether the claimed brain cancer is linked to exposure to environmental hazards during Gulf War I.
Important:
  • Examinations and medical opinions in these claims must be requested from the Veterans Health Administration (VHA).
  • The Acceptable Clinical Evidence (ACE) examination process may be used when processing these claims, when deemed appropriate.
References:  For more information on

IV.ii.1.E.3.d. Procedures for Requesting Examinations in Claims for SC of Brain Cancer

As with all VHA examination requests, ROs must use the Examination Request Builder (ERB) tool to generate an examination request.
Each examination request must include the
  • SWA Brain Cancer Fact Sheet, and
  • SWA Brain Cancer (MO).
Follow the steps in the table below to generate an examination request in the ERB tool that includes these required elements.
Step
Action
1
Initiate an examination request in ERB and ensure all information is completed regarding the Veteran.
Important:  If the Veteran is terminal, ensure Terminal is selected from the SPECIAL PRIORITY drop-down menu.
2
Select the appropriate examination type from the SELECT EXAM drop-down menu.
Example:  DBQ NEURO Central Nervous System
3
Select SWA Brain Cancer (MO) from the BASIS FOR EXAMINATION drop-down menu.
Note:  This step will generate the required background information with the medical opinion language in the examination request.
4
Identify the pertinent evidence in accordance with the procedures inM21-1, Part III, Subpart iv, 3.A.8.d.
Important:  The SWA Brain Cancer Fact Sheet, which will load to the user’s desktop once the ERB steps are complete, must be listed in the tabbed evidence.
5
Complete all other ERB steps as required.
6
Complete entries in the Compensation and Pension Record Interchange (CAPRI) using the procedures noted in M21-1, Part III, Subpart iv, 3.A.9.
Important:  If the Veteran is terminal, ensure TERMINAL is selected under the SPECIAL CONSIDERATIONS field.
7
Upload the SWA Brain Cancer Fact Sheet and the CAPRI examination request to the Veteran’s electronic claims folder.

Reference:  For more information on the ERB tool, see

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