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M21-1, Part IV, Subpart ii, Chapter 2, Section E – Service Connection for Disabilities Incurred as a Prisoner of War (POW)


In This Section

This section contains the following topics:
Topic Name

1.  General Information on FPOW Rating Activities


This topic contains general information on  FPOW rating activities, including

Change Date

March 20, 2011

IV.ii.2.E.1.a.  Designating Members of the Rating Activity to Handle FPOW Claims

Each regional office (RO) must designate at least one member of its rating activity to be specifically responsible for handling claims filed by former prisoners of war (FPOWs).
ROs with a rating activity composed of 25 or more Rating Veterans Service Representatives (RVSRs) must designate at least two of its members.  ROs with an insufficient number of RVSRs may make alternate arrangements consistent with individual circumstances.

IV.ii.2.E.1.b.  Purpose of FPOW Rating Activities

The purpose of creating special FPOW rating activities is to ensure FPOW claims are handled and decided by those RVSRs who are
  • knowledgeable on issues affecting FPOWs, and
  • sensitive to the FPOW experience.

IV.ii.2.E.1.c.  VSCM and PMCM Responsibility for Selecting the FPOW Rating Activity

The Veterans Service Center Manager (VSCM) and Pension Management Center Manager (PMCM) must select all FPOW rating activity members.

IV.ii.2.E.1.d.  Members of the FPOW Rating Activity

Each FPOW rating activity
  • must consist of two regular members and one alternate, and
  • should include a medical member, if available.
Note:  Except in unusual circumstances, only designated members or alternate members of the special rating activity may sign rating decisions involving FPOWs.

IV.ii.2.E.1.e.  Responsibilities of the FPOW Rating Activity

The primary responsibility of the FPOW rating activity is to ensure that disability claims filed by FPOWs are handled properly.
All members of the FPOW rating activity are expected to be thoroughly familiar with all laws, regulations, and directives concerning FPOWs.
Note:  The rating activity must exercise the utmost care and compassion in deciding FPOW claims.

2.  Deciding Claims Involving FPOWs


This topic contains information on deciding claims involving FPOWs, including

Change Date

May 13, 2015

IV.ii.2.E.2.a.  Considering All Relevant Laws, Regulations, and Directives for FPOW Claims

All claims filed by FPOWs must be adjudicated in accordance with all sections of the laws, regulations, and directives concerning such claims.
References:  For more information on

IV.ii.2.E.2.b.  Liberal Application of Directives Per 38 CFR 3.304(e) in FPOW Claims

In accordance with 38 CFR 3.304(e), the Department of Veterans Affairs (VA) employs a liberal approach when adjudicating claims for service connection (SC) from FPOWs.
This policy is based on the following two important factors
  • deficient or completely absent service treatment records (STRs), causing difficulty in providing evidence of disease or injuries suffered during or immediately prior to confinement, and
  • the physical and mental disabilities caused by internment as a prisoner of war (POW) may not manifest until many years after active duty service.

IV.ii.2.E.2.c.  VA Responsibilities When Adjudicating Claims From FPOWs

Assume all disabilities and/or symptoms claimed by the Veteran resulted from his/her POW experiences unless the Veteran specifically states otherwise.
Even though the Veteran has not alleged a specific disability, symptoms reported by the Veteran may be the result of
  • the POW experience, or
  • diseases subject to presumptive service connection.
In addition, give careful consideration to the Veteran’s POW experiences, particularly in reviewing disabilities that are claimed or diagnosed for the first time several years after service.

IV.ii.2.E.2.d.  Considering the Adequacy of Medical Evidence in FPOW Claims

Medical evidence that is current, accurate, and complete is paramount.  Examine medical evidence thoroughly to determine whether it is adequate to evaluate the disabilities under consideration.  Request a physical examination to supplement the evidence when necessary.
Ensure that a determination is not made on the basis of medical evidence that is not current or that is incomplete with regard to the disabilities under consideration.
Important: If the Veteran was not previously examined under an FPOW Protocol Disability Benefits Questionnaire, request such an examination.
References:  For more information on

IV.ii.2.E.2.e.  Statements from FPOWs as Evidence of Disability

Accept the statements of FPOWs about the disabilities or diseases incurred during or immediately prior to confinement as proof of service incurrence, as long as residual disability exists that can be attributed to the alleged service incident.
In addition, carefully consider the statements of former camp comrades, if offered in support.
Note:  If these statements are inconsistent with other evidence of record, contact the Veteran to provide clarification of any discrepancies.

IV.ii.2.E.2.f.  Ensuring Complete Development of FPOW Claims

Since certain disorders, such as the chronic residuals of nutritional deficiency, may manifest themselves through a variety of symptoms,
  • ensure that examinations are complete and comprehensive, and
  • afford the Veteran every opportunity to present a complete and accurate picture of his/her POW-related disabilities.

IV.ii.2.E.2.g.  Finding a Reasonable Basis for Establishing SC in FPOW Claims

To support a grant of SC, the evidence of record must establish a reasonable connection between the Veteran’s current disabilities and his/her experiences while a POW.
  • Intercurrent diseases or injuries, shown to be the cause of the disabilities under consideration, may preclude the establishment of SC.
  • Evidence of treatment or observation of the claimed disability during service is not required.
  • A lack of a history showing continuity or chronicity of the claimed disabilities since separation from service, although an important factor generally, is not by itself sufficient to justify denying SC.

IV.ii.2.E.2.h.  Requesting an Advisory Opinion in FPOW Claims

If it is unclear whether a condition is a residual of the POW experience, submit the claim to the Compensation Service mailbox, VAVBAWAS/CO/21Q&A, for an advisory opinion.
Reference:  For more information on Compensation Service guidance and advisory opinions, see M21-1, Part III, Subpart vi, 1.A.

3.  Presumption of SC for FPOWs


This topic contains information on presumptive SC for FPOWs, including

Change Date

May 13, 2015

IV.ii.2.E.3.a.  Establishing Presumptive SC Under 38 CFR 3.309(c)

The diseases specified in 38 CFR 3.309(c)(1) and (2) must be presumed to be SC if they become 10 percent or more disabling at any time after service and the Veteran has qualifying POW service.
References:  For more information on

IV.ii.2.E.3.b.  Disabilities Presumed to be SC for  FPOWs Under 38 CFR 3.309(c)

The disabilities presumed to be SC for FPOWs can be found at 38 CFR 3.309(c).
  • The disabilities in 38 CFR 3.309(c)(1) apply to all FPOWs, regardless of the length of detainment.
  • The disabilities in 38 CFR 3.309(c)(2) apply only to FPOWs who were detained for 30 days or longer.
  • The presumption of SC for organic residuals of frostbite applies if it is determined that the Veteran was interned in climactic conditions consistent with the occurrence of frostbite.
  • The presumption of SC for osteoporosis if the Veteran has posttraumatic stress disorder (PTSD) applies to claims received on or after October 10, 2008.
  • The presumption of SC for osteoporosis if the Veteran was detained for more than 30 days and does not have PTSD applies to claims received on or after September 28, 2009.
Reference:  For more information on diseases and disabilities subject to a presumption of SC, see 38 U.S.C. 1112.

IV.ii.2.E.3.c.  Absence of Evidence in Service Records of Presumptive Disabilities in FPOW Claims

Since the disabilities listed in 38 CFR 3.309(c) are presumed to be service- connected a record of their treatment or existence during service is not required.
Do not deny SC for one of these conditions predicated solely upon a deficiency in the Veteran’s STRs.

IV.ii.2.E.3.d.  Assigning Noncompensable Evaluations in FPOW Claims

Consider the possibility that the disability at issue was more severely disabling in the past, even if residuals currently exist but not to a degree warranting the assignment of a compensable evaluation.
If this is the case, the establishment of SC with a noncompensable evaluation may be in order.
Note:  The law and regulations do not require a current finding of disability warranting the assignment of a compensable evaluation at the time the claim for SC is filed.  Historical evidence of a compensable evaluation is acceptable to grant SC on a presumptive basis even if the disability is currently noncompensable.

IV.ii.2.E.3.e.  Denying Presumptive SC for an FPOW Claim

Before denying presumptive SC for an FPOW, at least one of the following two conclusions must be reached based on a thorough review of the evidence of record
  • the disability in question cannot be associated with the Veteran’s POW experiences (for example, the claimed condition was the result of an intercurrent disease or injury per 38 CFR 3.307(d)), or
  • the Veteran was never diagnosed with the disability in question.

4.  Considering SC for Certain Disabilities of FPOWs


This topic contains information on considering SC for certain disabilities of FPOWs, including

Change Date

May 13, 2015

IV.ii.2.E.4.a.  Considering SC for Residuals of Frostbite

Internment as a POW in climatic conditions consistent with the occurrence of frostbite is a prerequisite to establishing SC on a presumptive basis for organic residuals of frostbite.
  • Frostbite injury may occur at different temperatures and after different lengths of exposure, depending on the individual.
  • If a Veteran was a POW during seasons other than winter, the possibility of exposure to climatic conditions consistent with permanent frostbite injury must not be eliminated without careful consideration.
Reference:  For more information on rating residuals of cold injury, see M21-1, Part III, Subpart iv, 4.E.2.

IV.ii.2.E.4.b.  Considering SC for  Peptic Ulcer Disease

For rating purposes, a diagnosis of peptic ulcer is not sufficiently specific.  To properly evaluate the disability, the diagnosis must be supported by evidence adequately identifying the particular location of the ulcer.
Reference:  For more information on rating peptic ulcer disease, see 38 CFR 4.110.

IV.ii.2.E.4.c.  Considering SC for Peripheral Neuropathy

Peripheral neuropathy is subject to a presumption of SC under 38 CFR 3.309(c),except when the evidence establishes that peripheral neuropathy is directly related to infectious causes which are unrelated to an FPOW’s detainment.
  • Review the circumstances of the Veteran’s internment as it may have included exposure to infectious agents.
  • The possibility of nutritional deficiency during internment and resultant lowering of the body’s resistance to infection must be considered.
  • Medical evidence must establish a current diagnosis of peripheral neuropathy.

IV.ii.2.E.4.d.  Distinguishing Between Post-Traumatic Arthritis and Degenerative Arthritis in an FPOW Claim

If a Veteran of advanced age with multiple joint arthritis alleges trauma as the cause of arthritis at all or some of the disease sites, the rating activity must take care to distinguish between post-traumatic arthritis and degenerative or age-related arthritis when considering SC.
In such situations, obtain the most complete account possible of the traumatic incident.  Information that should be available for consideration includes
  • the nature of the trauma
  • a statement of the type and severity of the injuries received, and
  • the frequency of traumatic injury, such as how often an FPOW might have been beaten by his captors.
Important:  A reasonable basis for an award of SC might include
  • the appearance of arthritis at an earlier age than would be expected normally, or
  • confinement of arthritis to the location of the alleged trauma, regardless of the age at which it appears.
Note:  A medical opinion from a physician qualified to conduct POW examinations may be necessary to determine whether a current diagnosis of arthritis is consistent with the traumatic injuries reported by the FPOW.
Reference:  For more information on POW examiner qualifications, see VHA Directive 2011-018.

IV.ii.2.E.4.e.  Final Responsibility for Determining SC for Post-Traumatic Osteoarthritis in an FPOW Claim

The rating activity has the final responsibility for determining whether a relationship exists between the development of arthritis and the Veteran’s experiences as a POW.
Note:  Any reasonable doubt arising after review of the evidence must be resolved in favor of the Veteran.

IV.ii.2.E.4.f.  Considering SC for Osteoporosis – PTSD Diagnosed

Effective October 10, 2008, a presumption of SC was established for osteoporosis under 38 CFR 3.309(c)(1) for FPOWs who
  • were detained or interned for any period of time, and
  • have a diagnosis of PTSD.
Note:  PTSD is the only anxiety disorder recognized under 38 CFR 3.309(c)(1) as being associated with osteoporosis.

IV.ii.2.E.4.g.  Considering SC for Osteoporosis – PTSD Not Diagnosed

Effective September 28, 2009, a presumption of SC was established for osteoporosis under 38 CFR 3.309(c)(2) for FPOWs who were detained or interned for 30 days or longer.
Note:  This presumption is based, at least in part, on the likely nutritional deprivation experienced during longer (30 days or more) periods of captivity.

IV.ii.2.E.4.h.  FPOW Claims With Diagnoses of Both Osteoporosis and Arthritis

Many FPOWs who claim SC for osteoporosis, evaluated under 38 CFR 4.71(a), diagnostic code (DC) 5013 based on joint manifestations, have already established SC for arthritis, which is also evaluated based on symptoms in skeletal joints.
If a claim involves diagnoses of both osteoporosis and arthritis, obtain a medical opinion as to the etiology of the symptoms affecting a particular joint or joints.
  • Arthritis is described as inflammation of a joint or joints.
  • Osteoporosis is described as inadequate bone formation resulting in low bone mass, microscopic deterioration of bone tissue, and increased bone fragility, which results in an increased incidence of fracture.

5.  Preparing a Rating Decision Involving a Presumption of SC


This topic contains information on preparing a rating decision involving a presumption of SC, including

Change Date

May 13, 2015

IV.ii.2.E.5.a.  Information Required in the POW Rating Decision

Rating decisions must contain a summary of all available information about the Veteran’s confinement as a POW, such as the
  • dates of confinement, and
  • name(s) of specific camp(s) or sector(s) in which the Veteran was confined.
Reference:  For more information on completing the rating decision narrative, seeM21-1, Part III, Subpart iv, 6.C.

IV.ii.2.E.5.b.  Citing Disabilities in an FPOW Claim

Use the POW special issue indicator when entering a decision in Veterans Benefits Management System Rating (VBMS-R) for all disabilities alleged to have been incurred or aggravated during the Veteran’s period of confinement as a POW.
Reference:  For more information on special issue indicators in VBMS-R, seeVBMS-Rating User Guide.

IV.ii.2.E.5.c.  Considering the Results of the POW Protocol Examination

If the results of the FPOW protocol examination were considered as evidence, dispose of the following under the appropriate rating codes
  • all disabilities identified by the medical examiner, and
  • all complaints mentioned by the Veteran that are indicative of a specific, ratable disorder.

IV.ii.2.E.5.d.  Coding Specific FPOW Disabilities

Use the information below to code specific FPOW disabilities.
If the disability is …
Then …
peripheral neuropathy
ensure that the
  • last two digits of the DCs used, DCs 8510 through 8730, correspond to the actual nerve involved, and
  • second digit of the DC (5, 6 or 7) accurately reflects the symptomatology shown, such as paralysis, neuritis, or neuralgia.
peptic ulcer disease
award SC for those disorders independently ratable under DCs
  • 7304
  • 7305
  • 7306
  • 7308, or
  • 7348.
Note: The appropriate DC must be used to identify the location of the ulcer or residual disability.
Reference: For more information on rating peptic ulcer disease, see

IV.ii.2.E.5.e.  VSCM Review of FPOW Rating Decisions Prior to Promulgation

The VSCM must review all rating decisions involving FPOWs prior to promulgation.
The review must ensure compliance with all laws, regulations, and directives affecting claims from FPOWs.
Note:  Authority for reviewing these ratings may not be delegated to a designee lower than a coach.

6.  History of Disabilities Subject to Presumptive SC for FPOWs


This topic contains information on the history of disabilities subject to presumptive SC for FPOWs, including the

Change Date

May 13, 2015

IV.ii.2.E.6.a.  History Behind the Length of Confinement Requirement for FPOWs

Effective December 16, 2003, Public Law (PL) 108-183 eliminated the length of confinement requirement of 30 days or longer for the following disabilities
  • psychosis
  • any of the anxiety states
  • dysthymic disorder (or depressive neurosis)
  • organic residuals of frostbite, and
  • post-traumatic arthritis.
For claims received from October 1, 1981, through December 15, 2003, an FPOW must have been confined for 30 days or longer to be eligible for a presumption of SC for any of the disabilities listed in 38 CFR 3.309(c).
For claims received before October 1, 1981, confinement of six months or longer was required.
Note:  Certain disabilities are established under 38 CFR 3.309(c)(1) without regard to length of POW confinement.
Reference:  For more information on length of confinement requirements, see

IV.ii.2.E.6.b.  History of PLs and Federal Register Citations for FPOW Diseases

The table below contains the history of the PLs and Federal Register citations that have authorized a presumption of SC for the disabilities listed in 38 CFR 3.309(c).
PL or Federal Register Citation
PL 91-376, effective August 12, 1970
  • Avitaminosis
  • beriberi, including beriberi heart disease
  • chronic dysentery
  • helminthiasis
  • malnutrition, including optic atrophy associated with malnutrition and any other nutritional deficiency
  • pellagra, and
  • psychosis.
  • No listed disease, other than psychosis, has ever been subject to any time limit for compensable manifestations.
  • Effective
    • August 12, 1970, compensable manifestations of psychosis were required within 2 years of separation from service, and
    • October 1, 1981, the time limit for compensable manifestations of psychosis was removed.
  • PL 91-376 was amended effective August 24, 1993, to include ischemic heart disease in former POWs who experienced localized edema during captivity.
PL 97-37, effective October 1, 1981
Any of the anxiety states.
PL 98-223, effective October 1, 1983
Dysthymic disorder or depressive neurosis.
PL 99-576, effective October 1, 1986
  • Organic residuals of frostbite, if it is determined that the Veteran was interned in climatic conditions consistent with the occurrence of frostbite, and
  • post-traumatic osteoarthritis.
PL 100-322, effective May 20, 1988
  • Irritable bowel syndrome
  • peptic ulcer disease, and
  • peripheral neuropathy, except where directly related to infectious causes.
PL 108-183, effective December 16, 2003
  • Cirrhosis of the liver.
69 FR 60083, effective October 7, 2004
  • Atherosclerotic heart disease
  • hypertensive vascular disease, and
  • stroke.
PL 110-389, enacted October 10, 2008
  • Osteoporosis, if PTSD has also been diagnosed.
74 FR 44288, effective September 28, 2009
  • Osteoporosis (no requirement for PTSD diagnosis).
Transmittal-Sheet-pt04_sp02_TS_10-05-10.docx May 21, 2019 41 KB
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