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M21-1, Part IV, Subpart ii, Chapter 2, Section A – Deciding Claims for Disability Compensation

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4

1.  Reviewing the Status of Claims


Introduction

This topic contains information on issues to consider when reviewing the status of claims for disability compensation, including

Change Date

February 19, 2019

IV.ii.2.A.1.a.  Disabilities for Which SC Must Be Considered

When deciding an original claim for compensation, or when supplemental service treatment records (STRs) are received following promulgation of an original rating decision, the rating activity must
  • consider service connection (SC) for all claimed disabilities, based on a sympathetic reading of the claim, and
  • consider soliciting a claim for other chronic, unclaimed disabilities noted in the STRs.
Exception:  If a claimant or his/her authorized representative submits supplemental STRs, the rating activity must take the actions described in the preceding bullets only if the STRs are accompanied by the required standard claim form.
References:  For more information on

IV.ii.2.A.1.b.  Mere Existence of Medical Records Does Not Constitute a Claim

The mere existence of medical records does not constitute a claim.  There must be some intent by the claimant to apply for a benefit.
Notes:
  • Claims for an increased rating were previously an exception to that rule under the historical provisions of 38 CFR 3.157(b).
  • The Standard Claims and Appeals Form regulation eliminated 38 CFR 3.157 and requires submission of claims on prescribed forms effective March 24, 2015.

IV.ii.2.A.1.c.  Claims Mentioning Exposure but Not Specifying a Disability

A claim mentioning an exposure but not specifying a disability from the exposure is not substantially complete.
Reference:  For more information on claims that do not specify a disability but allege exposure, see M21-1, Part I, 1.B.1.h.

IV.ii.2.A.1.d.  Fractures Discovered in STRs Without a Claim

Fractures constitute a chronic disability for the purposes of soliciting a claim.
If the Veteran has not claimed a fracture and STRs contain an x-ray or other objective evidence of a fracture in service, send the Veteran a letter to invite the claim.
Reference:  For more information on SC for fractures documented in service, seeM21-1, Part III, Subpart iv, 4.A.8.a.

IV.ii.2.A.1.e.  Soliciting a Claim for a Chronic Unclaimed Disability

When soliciting a claim for SC for a chronic, unclaimed disability
Include the following language in the letter:
We have reviewed your records and they suggest you may be entitled to an additional benefit.  If you want to file a claim for [insert chronic disability] please submit a completed VA Form 21-526EZ, Application For Disability Compensation And Related Compensation Benefits, to the appropriate address listed on the attached Where to Send Your Written Correspondence chart.  You can download the form at http://www.va.gov/vaforms or you can call us at 1-800-827-1000. We recommend you return the form as soon as you can in order to ensure the earliest possible payment date if an award is authorized.
Notes:
  • Do not establish end product (EP) control or initiate development or duty-to-notify/assist procedures until the Veteran responds affirmatively to the letter.
  • When the Veteran responds affirmatively, the date of claim of the EP is the date the regional office received the claim.

IV.ii.2.A.1.f.  References Concerning the Selection of Effective Dates

For information on the selection of appropriate effective dates when deciding claims for disability compensation, see

 2.  Review of Diagnoses


Introduction

This topic contains information on issues to consider when reviewing medical evidence for diagnoses in claims for disability compensation, including

Change Date

February 19, 2019

IV.ii.2.A.2.a.  Subthreshold Diagnoses

When specific diagnostic criteria exists for a disability, a treating physician may utilize a subthreshold diagnosis for the purpose of treating the symptoms when not all symptoms required for the diagnosis are present.  Subthreshold diagnoses, such as pre-hypertension, pre-diabetes, Parkinson-like tremor, and others, are not adequate for use as a confirmed diagnosis for rating purposes.  When a subthreshold diagnosis is made and the known diagnostic criteria are clearly not met, do not return a medical examination to clarify the diagnosis.
Although a subthreshold diagnosis is acceptable for medical treatment purposes, it is not considered a ratable disability for compensation purposes.
Reference:  For more information on considering a diagnosis of pre-hypertension, see M21-1, Part III, Subpart iv, 4.G.3.d.

IV.ii.2.A.2.b.  Elective Procedures

Elective procedures, such as vasectomy, cosmetic breast reduction, or kidney donation, are not congruent with the provisions required for the purpose of SC of a disease or injury incurred coincident with a Veteran’s active service.  However, unusual or unanticipated outcomes resulting in an actually disabling condition that arise as a result of an in-service elective procedure may be subject to SC.
Reference:  For more information on considering SC for

IV.ii.2.A.2.c.  Diagnosis of Pain

Pain alone, even in the absence of a specific diagnosis or otherwise identified disease or injury, may constitute a disability under 38 U.S.C. 1110 or 38 U.S.C. 1131 for which SC may be granted.
The Veteran’s pain must result in functional impairment of earning capacity to constitute a disability.  The term disability under 38 U.S.C. 1110 refers to the functional impairment of earning capacity, not the underlying cause of such disability.  Therefore, pain alone, even in the absence of a diagnosis, can serve as a functional impairment and qualify as a disability under 38 U.S.C. 1110 or 38 U.S.C. 1131 irrespective of the underlying cause.
  • Functional impairment of earning capacity must be demonstrated by credible medical and/or lay evidence.  Functional impairment of earning capacity refers to limited ability or inability to perform occupational tasks to the extent that work performance, thus earning capacity, is impaired.  Examples of functional impairment of earning capacity include, but are not limited to,
    • inability to perform certain movements or tasks due to pain
    • time lost from work due to pain, or
    • pain resulting in increased fatigability or incoordination affecting job performance.
  • Subjective pain does not, by itself, establish the presence of a disability for the purposes of establishing SC.  The decision maker must weigh a Veteran’s lay assertion of pain against any contrary medical or other evidence in determining the probative value of the evidence of record for the purpose of deciding whether a current disability is demonstrated.
  • The pain must cause functional impairment of earning capacity to constitute a disability, but there is no requirement that the pain manifest to a compensable level to establish the presence of a current disability under the law.
  • Pain resulting in functional impairment of earning capacity is sufficient evidence of a disability for any body system and is not limited to the musculoskeletal body system.
Notes:
  • The Federal Circuit, in Saunders v. Wilkie, 886 F.3d 1356 (2018), overturned the longstanding Court of Veterans Appeals holding inSanchez-Benitez v. West, 13 Vet.App. 282 (1999) that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which SC may be granted.
  • Saunders addresses what a “disability” is for purposes of obtaining SC under 38 U.S.C. 1110.  A separate case, Petitti v. McDonald, 27 Vet.App. 415 (2015), addresses the appropriate rating under VA regulations for musculoskeletal disabilities already deemed to be service-connected (SC) disabilities.
    • Saunders pertains to the issue of entitlement to SC and governs that a claimant’s pain “must amount to a functional impairment of earning capacity” to constitute a disability.  Saunders is applicable for all body systems.
    • Petitti pertains to the issue of the disability evaluation assigned for a disability already found to be SC.  Petitti directs that when assigning a disability evaluation, assuming 38 CFR 4.59 and 38 CFR 4.71a, diagnostic codes (DCs) 5002 or 5003 are for application, “painful, albeit nonlimited, motion” is entitled to a minimum compensable rating per joint.  This holding is applicable to musculoskeletal disabilities.
  • The Saunders holding is not a liberalizing rule warranting application of 38 CFR 3.114.
  • The Saunders holding is dated April 3, 2018, and applies to all claims or legacy appeals pending or received on or after that date.
References:  For more information on

IV.ii.2.A.2.d.  Examples of Diagnosis of Pain

Example 1:  The Veteran, during a VA examination, reports bilateral knee pain while performing various activities.  The examiner finds no anatomic abnormality, weakness, or reduced range of motion; however, the examiner notes that the Veteran has functional limitations on walking, is unable to stand for more than a few minutes, and sometimes requires use of a cane or brace.  A diagnosis of subjective bilateral knee pain is rendered and the examiner comments that the pain leads to increased absenteeism and impacts the Veteran’s ability to complete daily activities.  Although a current diagnosis is not provided, a current disability under38 U.S.C. 1110 is established as the pain is shown to result in functional impairment of earning capacity.
Example 2:  The Veteran, during a VA examination, complains of right shoulder pain.  The examiner finds no pain, weakness, or abnormality.  Repetitive motion does not elicit pain, and the examiner concludes that the Veteran would not develop pain during flare-ups or repeated use over time.  The examiner comments that the subjective complaints of right shoulder pain would not impact the Veteran’s ability to perform any type of occupational task.  Although the Veteran’s complaints of right shoulder pain are credible, a current disability under 38 U.S.C. 1110 is not established as the evidence fails to demonstrate that there is any functional impairment of earning capacity due to the subjective right shoulder pain.
Example 3:  The Veteran reports experiencing headaches two to three times a week during a VA examination.  He describes the headaches as throbbing with visual changes that require him to lie down for several hours to obtain relief.  The Veteran, in support of his claim, provides documentation from his employer indicating that the Veteran had to leave work several times over the past few months due to headaches as well as private medical records showing he was seen by his family physician for headaches.  The examiner found no obvious abnormalities associated with the headaches.  Subjective cephalgia is diagnosed.  The examiner’s assessment of functional impairment is that the cephalgia impacts the Veteran’s ability to perform occupational tasks since the frequent episodes are so painful that he needs to cease all activity for several hours to obtain relief.  A current disability is demonstrated under 38 U.S.C. 1110.  Although the cephalgia is subjective, the evidence is credible and demonstrates that the cephalgia results in functional impairment of earning capacity.
Example 4:  The Veteran complains of right knee pain during a VA examination.  The examiner finds no anatomic abnormality, weakness, or reduced range of motion of the right knee.  The examiner indicates that flare-ups or repeated use over time would not result in additional functional loss to include pain and loss of motion.  The examiner does not provide any analysis as to whether the right knee pain impacts the Veteran’s ability to perform occupational tasks.  A diagnosis of subjective right knee pain is given.  In this case, the examination report should be returned for the examiner to provide analysis as to whether the right knee pain impacts the Veteran’s ability to perform occupational tasks unless this can be established by other credible evidence of record.

IV.ii.2.A.2.e.  Considering Direct SC for Obesity

Obesity per se is not a disease or injury for the purposes of 38 U.S.C 1110 and 38 U.S.C. 1131 and therefore may not be SC on a direct basis.
Obesity cannot qualify as an in-service event because it occurs over time and is based on various external and internal factors, as opposed to being a discrete incident or occurrence, or a series of discrete incidents or occurrences.
Reference:  For more information on considering SC for obesity, seeVAOPGCPREC 1-2017.

IV.ii.2.A.2.f.  Considering Secondary SC for Obesity

Obesity per se is not a “disability” for the purposes of SC under 38 CFR 3.310 for secondary SC.  If obesity resulting from a SC disease or injury is found to produce impairment beyond that contemplated by the applicable provisions of the rating schedule, consider an extra-schedular rating under 38 CFR 3.321(b)(1) for SC based on that impairment.
Obesity may be an “intermediate step” between a SC disability and a current disability that may be SC on a secondary basis under 38 CFR 3.310(a).
To determine whether obesity is an intermediate step between a SC disability and the development of a current disability that may be SC on a secondary basis, the following criteria must all be satisfied:
  • the SC disability must have caused the Veteran to become obese
  • the obesity as a result of the SC disability must have been a substantial factor in causing the potential secondary disability, and
  • the potential secondary disability would not have occurred but for the obesity caused by the SC disability.
Example:  A Veteran claims SC for hypertension on the basis that his SC back disability caused obesity due to lack of exercise, which led to hypertension.  To grant SC, an adjudicator would have to resolve the following issues: (1) whether the SC back disability caused the Veteran to become obese; (2) if so, whether the obesity as a result of the SC disability was a substantial factor in causing hypertension; and (3) whether the hypertension would not have occurred but for obesity cause by the SC back disability.  If these questions are answered in the affirmative, the hypertension may be SC on a secondary basis.
References:  For more information on

IV.ii.2.A.2.g.  Examples of ObesityDeterminations 

Extra-Schedular Evaluation Example:  A Veteran is SC for rheumatoid arthritis with a 40-percent evaluation and is shown to be unable to exercise due to the debilitating nature of the disease.  Competent medical evidence shows that the Veteran developed obesity as a result of the inability to exercise and the obesity results in additional pain, weakness, and instability of the joints that produces functional loss beyond that shown to solely result from the rheumatoid arthritis.  The evidence does not support a higher schedular evaluation under 38 CFR 4.71a, DC 5002 or a higher evaluation based on separate evaluation of the affected joints.
In view of the record showing that obesity results from the SC rheumatoid arthritis and produces impairment beyond that contemplated by the regular rating criteria, a determination should be rendered as to whether referral for consideration of an extra-schedular evaluation under 38 CFR 3.321(b)(1) is warranted.
Intermediate Step Example:  The Veteran’s SC psoriasis is manifested by constant flare-ups that require near continuous treatment with Prednisone for management.  The near continuous use of Prednisone on a long-term basis resulted in obesity, which was medically shown to lead to the development of coronary artery disease (CAD).  Based on the evidence, the obesity is shown to be an intermediate step between the SC psoriasis and CAD, which satisfies the proximate cause requirement under 38 CFR 3.310(a) to establish SC for CAD on a secondary basis.
Reference:  For more information on extra-schedular evaluations, see

IV.ii.2.A.2.h.  Abnormal Laboratory Findings

Abnormal laboratory findings, even if diagnosed, are not themselves disabilities for VA purposes.  Such findings include, but are not limited to,
  • elevated blood sugar
  • hyperlipidemia
  • elevated triglycerides, or
  • elevated cholesterol.
Notes:
  • Clarification may be necessary when there is a claim for a benefit based upon laboratory findings.
  • Do not solicit a claim based merely on abnormal laboratory findings discovered in the STRs.
Example:  A claim for SC for “blood sugar” or “high blood sugar” may have been intended as a claim for diabetes.  Development could substantiate that elevated blood sugar readings in service represented the onset of diabetes first diagnosed after service or that diabetes may have been diagnosed in a presumptive period.

3.   Action to Take After Receiving Supplemental STRs


Introduction
This topic contains information on the action to take after receiving supplemental STRs, including

Change Date

February 19, 2019

IV.ii.2.A.3.a.  Consideration of Supplemental STRs Submitted by a Claimant or Representative

The submission of supplemental, non-duplicative STRs by a claimant or a claimant’s authorized representative does not constitute a claim unless they are accompanied by the required standard claim form identifying the claimed disability(ies).
If the required standard claim form does not accompany the STRs, follow the instructions in M21-1, Part III, Subpart ii, 2.C.6, for requesting an application from the claimant.
Note:  If the supplemental STRs submitted by the claimant or representative are duplicative of evidence already considered, annotate the records, Duplicate STRs reviewed, NAN (no action needed).
Reference:  For more information on required standard claim forms, see M21-1, Part III, Subpart ii, 2.B.1.b.

IV.ii.2.A.3.b.  Notifying Claimants of a Rating Decision Based on Supplemental STRs

All rating decisions awarding SC, an increased disability evaluation, or death benefits based on supplemental STRs that a claimant or his/her representative submits or a claims processor discovers in the Veteran’s electronic claims folder must contain the following language:
“VA has received additional service treatment records that were previously unavailable.  The following decision is based on the additional medical evidence.”

4.  Evaluating Pending Claims When a Veteran Returns to Active Duty


Introduction

This topic contains procedures for evaluating claims that are pending when a Veteran returns to active duty, including

Change Date

February 19, 2019

IV.ii.2.A.4.a.Effect of Return to Active Duty on VA Benefits

Reentry into active duty generally does not affect a Veteran’s potential entitlementto VA benefits.  However, a Veteran who is on active duty cannot receive bothactive service pay and VA compensation for the same period.
Reference:  For more information on the effect of a return to active duty on VA benefits, including the election of benefits during the period of active duty, see

IV.ii.2.A.4.b.Effect of Return to Active Duty on a Veteran’s Claim

A Veteran’s reentry into active duty generally does not alter the legal rights and responsibilities of the Veteran and VA with respect to pending claims.
  • The statutes and regulations requiring VA to provide notice and assistance apply to claimants who have returned to active duty to the same extent as to all other claimants.
  • VA may not deny a claim solely because the claimant’s return to active duty temporarily prevents VA from conducting an examination or other required procedure.  VA may suspend or defer action on a claim until the Veteran becomes available for examination or other action.
Notes:
  • If the Veteran is available to attend an examination while on active duty, then proceed with the examination.
  • If a Veteran dies following his/her return to active duty but before a pending claim is decided, the pending claim may provide the basis for an award of accrued benefits.  Accrued benefits consist only of amounts due and unpaid to the deceased beneficiary.
Reference:  For more information on entitlement to accrued benefits based on a claim pending at the time of the Veteran’s death, see

IV.ii.2.A.4.c.  Suspending Action on a Claim Due to Return to Active Duty

If a Veteran’s return to active duty renders VA unable to accomplish the duty to assist via requesting an examination, obtaining STRs, or fulfilling any other required development action, follow the steps in the table below to suspend action on the pending claim.
Step
Who Is Responsible
Action
1
development activity
Upon determining that a necessary development action cannot be completed due to the Veteran’s return to active duty status, ensure that all remaining development actions that can be completed have been undertaken.  Refer the claim to the
  • rating activity, if rating issues are pending, or
  • authorization activity, if no rating issues are pending.
2
rating activity (or authorization activity if authorization issues not requiring rating action are claimed)
Review the evidence of record to determine whether the development that cannot be undertaken impacts each claimed issue.
Refer to the table below for proper actions to take based on whether the incomplete development impacts the outcome of a claim.
If the development that cannot be undertaken is …
Then …
not relevant to the claimed issue
proceed with the grant or denial of the claimed issue.
relevant to the claimed issue, but the claimed issue can be granted in spite of the missing development
proceed with the grant of the claimed issue.
relevant to the claimed issue and would lead to denial or incomplete development for current evaluation of the claimed issue, if decided,
  • defer a decision on the claimed issue in the rating decision narrative and on the rating codesheet
  • advise the Veteran that the issue is deferred due to inability, as a result of his/her return to active duty, to obtain the evidence necessary to decide the claim, and
  • do not initiate deferral action in the Veterans Benefits Management System (VBMS).
Important:  Even if all issues are deferred, complete a rating decision addressing the deferred issues.
Example:  The issue of compensation for back condition is deferred for the following information:  further development of the claim.  Due to your return to active duty, we are unable to obtain [insert development that cannot be undertaken].  Action on your claim is suspended until your release from active duty.

Note:  The above procedure is an exception to the general rule that usually

  • requires all deferral action to be entered in VBMS, and
  • prohibits completion of a rating decision when all issues are deferred.
3
authorization activity
Use the table below to determine the proper notification actions to take when VA cannot decide a claim due to a Veteran’s return to active duty during the pendency of a claim.
If a …
Then …
partial rating was completed
  • notify the Veteran by
    • selecting the FREE TEXT OPTION from the AWARD LETTER INTERVIEW screen in VBMS, and
    • include free text in the WHAT WE DECIDED field as shown in M21-1, Part IV, Subpart ii, 2.A.4.d, and
    • add theReturned to Active Dutycorporate flash to the Veteran’s VBMS record, and
  • clear the pending EP.
Note:  There are no review rights for issues that were deferred as no decision has been made.
decision on all issues was deferred in the rating decision
  • complete award action in VMBS-Awards but reject the system-generated notification letter
  • send the Veteran theSuspension of Claim Due to Return to Active Dutyletter included in the Letter Creator tool, when applicable
  • since the system defaults to continuation of the EP at authorization, cancel the pending EP in SHARE after authorization of the award
  • add the Returned to Active Duty corporate flash to the Veteran’s VBMS record,  and
  • add a VBMS note explaining the reason for cancellation of the EP.
Note:  There are no review rights for issues that were deferred as no decision has been made.

IV.ii.2.A.4.d.  Exhibit:  Free Text for Decision Notice for Partial Deferral of Claims Pending At Return to Active Duty

Include the free text below in the What We Decided portion of the decision notice letter when
  • a partial decision is made on some issues but other issues are deferred, and
  • a claim must be suspended due to a Veteran’s return to active duty.
We received notification that you have returned to active duty.  Because of your return to active duty, we are unable to fulfill our legal requirements to assist you in obtaining the evidence necessary to make a decision on some issues you have claimed.  Specifically, we are unable to [insert description of development action that cannot be completed].  Without this evidence, we cannot determine entitlement to some of the benefits you are seeking.  A claim cannot be denied due solely to your return to active duty.
Until we can fulfill our duty to assist you in obtaining this evidence, we are suspending action on your claim. 
[If the incomplete development includes inability to schedule an examination, insert the following paragraph.]
If you are able to report for a medical examination to evaluate the claimed condition(s) while on active duty, please notify us of your availability and advise us of your location so that the examination may be scheduled at a VA facility in your current area.
When you are released from the current period of active duty, please notify us of your release, and advise us that you wish to resume action on your claim.  If we receive notification that you wish to resume action on the current claim within one year after your release from the current period of active duty, then we will be able to grant benefits, when warranted, based on the date of receipt of your original claim.  If we do not receive notice within one year, then your original claim will be considered abandoned.

IV.ii.2.A.4.e.  Method of Requesting Resumption of Suspended Claim

Upon a Veteran’s release from active duty, he or she must notify VA of the release from active duty and desire to resume a claim previously suspended as a result of the inability to develop the claim due to the return to active duty.
If the request is only for resumption of the prior claim, then there is no prescribed form required for the request.  However, if new issues are claimed, the new issues must be claimed on the appropriate prescribed form.

IV.ii.2.A.4.f.  Time Limit for Requesting Resumption of Suspended Claim

To preserve the original effective date, the request to resume the suspended claim must be received within one year after the Veteran’s release from the period of active duty that resulted in suspension of the claim.  If the request to resume the suspended claim is not received within one year of the release from the period of active duty that resulted in suspension of the claim, consider the claim abandoned.

For an abandoned claim

  • there is no requirement to provide notice, including notice of review rights, and
  • a subsequent claim for an abandoned issue is considered a new claim.
Note:  If a subsequent claim for SC is received and previously deferred issues remain on the codesheet but were abandoned due to the failure to request timely resumption of the claim, delete the deferred issues from the codesheet.  As the prior claims were undecided, they should not be shown as denied issues on the codesheet.  Rather, treat a subsequent claim for a previously abandoned issue as a new claim and do not require the submission of new and relevant evidence.
References:  For  more information on

IV.ii.2.A.4.g. Resumption of Suspended Claims

Follow the steps in the table below upon receipt of a request to resume a previously suspended claim following a Veteran’s release from active duty.
Step
Who Is Responsible
Action
1
intake processing center
Review the EP history to determine whether the prior EP was cleared or canceled.
Use the table below to determine the appropriate EP action to take upon receipt of a request for resumption of a suspended claim.
If the EP was …
Then establish 
cleared
EP 930 with a date of claim corresponding with the date of claim for the previously cleared EP controlling for the suspended claim.
cancelled
the appropriate rating EP with a date of claim corresponding with date of receipt of the current request to resume the suspended claim.
Note:  If new issues are being claimed, the new issues will be controlled under the same EP controlling the resumption of the suspended claim.
2
development activity
Undertake whatever development is necessary for
  • previously suspended issues, and
  • newly received claimed issues, if applicable.
Note:  If more than one year has passed since the Veteran was last provided notice under Section 5103 (via any of the accepted methods identified in M21-1, Part I, 1.B.1.d) for the deferred issues from the suspended claim, send the appropriate Section 5103 notice.
Reference:  For more information on Section 5103 notice requirements, see M21-1, Part I, 1.B.
3
rating activity (or authorization activity if non-rating issues are present)
Use the table below to determine which issues to address in the decision.
If …
Then in the same decision document, address  …
all issues were deferred at the time of the previously suspended claim
  • all deferred issues from the suspended claim, and
  • all newly claimed issues, if any.
a partial decision was completed for some issues on the suspended claim
  • only those issues from the suspended claim that were not decided, and
  • all newly claimed issues, if any.
Reference:   For more information on handling a Veteran’s return to and discharge from an additional period of active duty, see M21-1, Part III, Subpart v, 4.C.7.
4
authorization activity
Remove the Returned to Active Duty corporate flash from the Veteran’s VBMS record after all issues that were deferred at the time of return to active duty have been decided.

IV.ii.2.A.4.h.  Effect of Delay in Examining a Veteran Due to Return to Active Duty

When a Veteran is unavailable for examination for an extended period due to return to active duty, the lapse of time may make it difficult to determine the nature and extent of the Veteran’s disability for past periods relevant to the claim.  Consider all relevant evidence of record to ascertain the level of disability for prior periods of time.  Such evidence includes, but is not limited to
  • medical records from the most recent period of active duty
  • an examiner’s opinion, expressed to the extent possible, concerning the Veteran’s disability over the relevant past periods
  • private treatment records, and
  • non-medical evidence, including lay statements, describing the impact of the claimed mental or physical condition on the Veteran’s performance of
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