Overview
In This Section |
This section contains the following topics:
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1. Developing Claims Based on Southwest Asia Service
Change Date |
March 14, 2019
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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
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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
References: For more information on
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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.
Reference: For more information on locations considered as Southwest Asia theater of operations, see
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IV.ii.1.E.1.d. Requesting Service Department Records in a Southwest Asia Claim |
In addition to service treatment records (STRs), request
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.
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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
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.
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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
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2. Examinations in Claims Based on Southwest Asia Service
Change Date |
March 14, 2019
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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
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.d–l.
Important:
References: For more information on
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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
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
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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).
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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.e–l.
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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.
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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.
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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 3.303, 3.306, 3.307, 3.309, 3.310) – 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:
Reference: For more information on specialty and specialist examinations, seeM21-1, Part III, Subpart iv, 3.A.1.g and h.
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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.
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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.
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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:
Exception: Obtain an examination where the criteria in M21-1 Part IV, Subpart ii, 1.E.2.a are otherwise met when there is
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.
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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.
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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 illness”for 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
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Introduction |
This topic contains information on developing claims for SC of brain cancer based on Southwest Asia service, including
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Change Date |
March 14, 2019
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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:
Reference: For more information on considering direct SC for brain cancer, see M21-1, Part IV, Subpart ii, 2.D.1.r.
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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.
Reference: For more information on locations considered as Southwest Asia theater of operations, see
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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
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:
References: For more information on
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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
Follow the steps in the table below to generate an examination request in the ERB tool that includes these required elements.
Reference: For more information on the ERB tool, see |
5-5-17_Key-Changes_M21-1IV_ii_1_SecE.docx | May 21, 2019 | 77 KB |
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Historical_M21-1IV_ii_1_SecE_11-5-15.docx | May 21, 2019 | 71 KB |
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12-21-16_Key-Changes_M21-1IV_ii_1_SecE.docx | May 21, 2019 | 77 KB |
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9-28-18_Key-Changes_M21-1IV_ii_1_SecE.docx | May 21, 2019 | 61 KB |
3-14-19_Key-Changes_M21-1IV_ii_1_SecE.docx | May 21, 2019 | 61 KB |
11-5-15_Key-Changes_M21-1IV_ii_1_SecE.docx | May 21, 2019 | 67 KB |
Transmittal-M21-1MRIV_ii_1_SecE_TS.docx | May 21, 2019 | 38 KB |
in Chapter 1 Development, Part IV Compensation, DIC, and Death Compensation Benefits, Subpart ii Compensation
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